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Sample records for duplicate medical records

  1. Duplicate Medical Records: A Survey of Twin Cities Healthcare Organizations

    PubMed Central

    McClellan, Molly A.

    2009-01-01

    Duplicate medical records occur when a single patient is associated with more than one medical record number. This causes a dangerous and expensive issue for hospitals and health information technology. A survey was constructed to gather qualitative information from Twin Cities healthcare organizations. The goal was to determine baseline information regarding the recognition of the problems surrounding duplicate medical record creation and organizational strategies for resolutions. The survey demonstrated that all organizations acknowledged the importance and patient safety issue regarding the creation of duplicates but the strategies and solutions are varied. As defined in the Minnesota Alliance for Patient Safety5, the ultimate goal of this survey was to favorably impact patient safety. The deidentified results were disseminated to all participating organizations along with recommendations for system improvements in order to raise awareness of the issue and promote patient safety. PMID:20351892

  2. Electronic Documentation Support Tools and Text Duplication in the Electronic Medical Record

    ERIC Educational Resources Information Center

    Wrenn, Jesse

    2010-01-01

    In order to ease the burden of electronic note entry on physicians, electronic documentation support tools have been developed to assist in note authoring. There is little evidence of the effects of these tools on attributes of clinical documentation, including document quality. Furthermore, the resultant abundance of duplicated text and…

  3. Identifying and removing duplicate records from systematic review searches

    PubMed Central

    Kwon, Yoojin; Lemieux, Michelle; McTavish, Jill; Wathen, Nadine

    2015-01-01

    Objective The purpose of this study was to compare effectiveness of different options for de-duplicating records retrieved from systematic review searches. Methods Using the records from a published systematic review, five de-duplication options were compared. The time taken to de-duplicate in each option and the number of false positives (were deleted but should not have been) and false negatives (should have been deleted but were not) were recorded. Results The time for each option varied. The number of positive and false duplicates returned from each option also varied greatly. Conclusion The authors recommend different de-duplication options based on the skill level of the searcher and the purpose of de-duplication efforts. PMID:26512216

  4. The impact of a growing minority population on identification of duplicate records in an enterprise data warehouse.

    PubMed

    Duvall, Scott L; Fraser, Alison M; Kerber, Richard A; Mineau, Geraldine P; Thomas, Alun

    2010-01-01

    Patient medical records are often fragmented across disparate healthcare databases, potentially resulting in duplicate records that may be detrimental to health care services. These duplicate records can be found through a process called record linkage. This paper describes a set of duplicate records in a medical data warehouse found by linking to an external resource containing family history and vital records. Our objective was to investigate the impact database characteristics and linkage methods have on identifying duplicate records using an external resource. Frequency counts were made for demographic field values and compared between the set of duplicate records, the data warehouse, and the external resource. Considerations for understanding the relationship that records labeled as duplicates have with dataset characteristics and linkage methods were identified. Several noticeable patterns were identified where frequency counts between sets deviated from what was expected including how the growth of a minority population affected which records were identified as duplicates. Record linkage is a complex process where results can be affected by subtleties in data characteristics, changes in data trends, and reliance on external data sources. These changes should be taken into account to ensure any anomalies in results describe real effects and are not artifacts caused by datasets or linkage methods. This paper describes how frequency count analysis can be an effective way to detect and resolve anomalies in linkage results and how external resources that provide additional contextual information can prove useful in discovering duplicate records.

  5. The impact of a growing minority population on identification of duplicate records in an enterprise data warehouse.

    PubMed

    Duvall, Scott L; Fraser, Alison M; Kerber, Richard A; Mineau, Geraldine P; Thomas, Alun

    2010-01-01

    Patient medical records are often fragmented across disparate healthcare databases, potentially resulting in duplicate records that may be detrimental to health care services. These duplicate records can be found through a process called record linkage. This paper describes a set of duplicate records in a medical data warehouse found by linking to an external resource containing family history and vital records. Our objective was to investigate the impact database characteristics and linkage methods have on identifying duplicate records using an external resource. Frequency counts were made for demographic field values and compared between the set of duplicate records, the data warehouse, and the external resource. Considerations for understanding the relationship that records labeled as duplicates have with dataset characteristics and linkage methods were identified. Several noticeable patterns were identified where frequency counts between sets deviated from what was expected including how the growth of a minority population affected which records were identified as duplicates. Record linkage is a complex process where results can be affected by subtleties in data characteristics, changes in data trends, and reliance on external data sources. These changes should be taken into account to ensure any anomalies in results describe real effects and are not artifacts caused by datasets or linkage methods. This paper describes how frequency count analysis can be an effective way to detect and resolve anomalies in linkage results and how external resources that provide additional contextual information can prove useful in discovering duplicate records. PMID:20841858

  6. Duplicate publication rate decline in Korean medical journals.

    PubMed

    Kim, Soo Young; Bae, Chong-Woo; Hahm, Chang Kok; Cho, Hye Min

    2014-02-01

    The purpose of this study was to examine trends in duplicate publication in Korean medical articles indexed in the KoreaMed database from 2004 to 2009, before and after a campaign against scientific misconduct launched by the Korean Association of Medical Journal Editors in 2006. The study covered period from 2007 to 2012; and 5% of the articles indexed in KoreaMed were retrieved by random sampling. Three authors reviewed full texts of the retrieved articles. The pattern of duplicate publication, such as copy, salami slicing (fragmentation), and aggregation (imalas), was also determined. Before the launching ethics campaign, the national duplication rate in medical journals was relatively high: 5.9% in 2004, 6.0% in 2005, and 7.2% in 2006. However, duplication rate steadily declined to 4.5% in 2007, 2.8% in 2008, and 1.2 % in 2009. Of all duplicated articles, 53.4% were classified as copies, 27.8% as salami slicing, and 18.8% as aggregation (imalas). The decline in duplicate publication rate took place as a result of nationwide campaigns and monitoring by KoreaMed and KoreaMed Synapse, starting from 2006.

  7. Your Medical Records

    MedlinePlus

    ... to get records for non-emergency situations (like switching to a new doctor), it's best to give ... Your Medical Care Health Insurance Basics Finding Low-Cost Medical Care Health Insurance: Cracking the Code Questions ...

  8. Medical records seized.

    PubMed

    1998-04-17

    Police in San Jose, CA, seized medical records at a medical marijuana clinic to see if doctors recommended use of the drug. The seizure at Santa Clara County Medical Cannabis Center raised concerns among physicians, who fear their medical licenses may be revoked. Patients were equally concerned that their confidentiality could be compromised. Police said if doctors refuse to confirm that they have recommended marijuana to a patient, the patient will be asked to sign a release. If the patient refuses, other corroboration will be sought. California voters legalized the medical use of marijuana in 1996; however, Federal and State officials continue to try to block implementation of the law.

  9. Access to Medical Records.

    ERIC Educational Resources Information Center

    Cooper, Nancy

    Although confidentiality with regard to medical records is supposedly protected by the American Medical Associaton's principles of Ethics and the physician-patient privilege, there are a number of laws that require a physician to release patient information to public authorities without the patient's consent. These exceptions include birth and…

  10. Private Medical Record Linkage with Approximate Matching

    PubMed Central

    Durham, Elizabeth; Xue, Yuan; Kantarcioglu, Murat; Malin, Bradley

    2010-01-01

    Federal regulations require patient data to be shared for reuse in a de-identified manner. However, disparate providers often share data on overlapping populations, such that a patient’s record may be duplicated or fragmented in the de-identified repository. To perform unbiased statistical analysis in a de-identified setting, it is crucial to integrate records that correspond to the same patient. Private record linkage techniques have been developed, but most methods are based on encryption and preclude the ability to determine similarity, decreasing the accuracy of record linkage. The goal of this research is to integrate a private string comparison method that uses Bloom filters to provide an approximate match, with a medical record linkage algorithm. We evaluate the approach with 100,000 patients’ identifiers and demographics from the Vanderbilt University Medical Center. We demonstrate that the private approximation method achieves sensitivity that is, on average, 3% higher than previous methods. PMID:21346965

  11. Medical records and record-keeping standards.

    PubMed

    Carpenter, Iain; Ram, Mala Bridgelal; Croft, Giles P; Williams, John G

    2007-08-01

    The structure of medical records becomes ever more critical with the advent of electronic records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Records Standards programme is developing generic standards for all entries into medical notes and standards for the content of admission, handover and discharge records. The Information Laboratory (iLab) focuses on hospital episode statistics and their use for monitoring clinician performance. Clinician endorsement of the work is achieved through extensive consultations. Generic medical record-keeping standards are now available. PMID:17882846

  12. Effects of Shared Electronic Health Record Systems on Drug-Drug Interaction and Duplication Warning Detection

    PubMed Central

    Rinner, Christoph; Grossmann, Wilfried; Sauter, Simone Katja; Wolzt, Michael; Gall, Walter

    2015-01-01

    Shared electronic health records (EHRs) systems can offer a complete medication overview of the prescriptions of different health care providers. We use health claims data of more than 1 million Austrians in 2006 and 2007 with 27 million prescriptions to estimate the effect of shared EHR systems on drug-drug interaction (DDI) and duplication warnings detection and prevention. The Austria Codex and the ATC/DDD information were used as a knowledge base to detect possible DDIs. DDIs are categorized as severe, moderate, and minor interactions. In comparison to the current situation where only DDIs between drugs issued by a single health care provider can be checked, the number of warnings increases significantly if all drugs of a patient are checked: severe DDI warnings would be detected for 20% more persons, and the number of severe DDI warnings and duplication warnings would increase by 17%. We show that not only do shared EHR systems help to detect more patients with warnings but DDIs are also detected more frequently. Patient safety can be increased using shared EHR systems. PMID:26682218

  13. Duplicate Records in the Bibliographic Utilities: A Historical Review of the Printing versus Edition Problem.

    ERIC Educational Resources Information Center

    Jones, Barbara; Kastner, Arno

    1983-01-01

    Printings and editions of a given monographic title are noted as major causes of duplicate bibliographic records in bibliographic networks. Considerations which cataloger must note--history of printing technology, cataloging rules, Library of Congress policy, local practices, and standards of bibliographic utilities--are discussed. Thirty-three…

  14. Tracking medication information across medical records

    PubMed Central

    Iglesias, Juan Eugenio; Rocks, Krupa; Jahanshad, Neda; Frias-Martinez, Enrique; Andrada, Lewellyn P.; Bui, Alex A.T.

    2009-01-01

    A patient’s electronic medical record can consist of a large number of reports, especially for an elderly patient or for one affected by a chronic disease. It can thus be cumbersome for a physician to go through all of the reports to understand the patient’s complete medical history. This paper describes work in progress towards tracking medications and their dosages through the course of a patient’s medical history. 923 reports associated with 11 patients were obtained from a university hospital. Drug names were identified using a dictionary look-up approach. Dosages corresponding to these drugs were determined using regular expressions. The state of a drug (ON, OFF), which determines whether or not the drug was being taken, was identified using a support vector machine with features based on expert knowledge. Results were promising: prec. ≈ recall ≈ 87%. The output is a timeline display of the drugs which the patient has been taking. PMID:20351862

  15. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 4 2011-10-01 2011-10-01 false Medical records. 460.210 Section 460.210 Public...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of medical records. (1) A PACE organization must maintain a single, comprehensive medical record for...

  16. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Medical records. 460.210 Section 460.210 Public...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of medical records. (1) A PACE organization must maintain a single, comprehensive medical record for...

  17. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Medical records. 460.210 Section 460.210 Public...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of medical records. (1) A PACE organization must maintain a single, comprehensive medical record for...

  18. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Medical records. 460.210 Section 460.210 Public...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of medical records. (1) A PACE organization must maintain a single, comprehensive medical record for...

  19. Behavioral health electronic medical record.

    PubMed

    Lawlor, Ted; Barrows, Erik

    2008-03-01

    The electronic medical record (EMR) will be an important part of the future of medical practice. Behavioral health treatment demands certain additions to the capabilities of a standard general medical EMR. The current focus on the quality management and financial aspects of the EMR are only initial examples of what this tool can do. It is important for behavioral health practitioners to understand that they must embrace this innovation and mold it into a product that serves their needs and the needs of their patients. An efficient and effective EMR will greatly assist the overall clinical enterprise in a number of important areas. PMID:18295041

  20. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 2 2013-07-01 2013-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  1. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 2 2012-07-01 2012-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  2. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 2 2014-07-01 2014-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  3. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  4. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 5 Administrative Personnel 3 2013-01-01 2013-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  5. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 5 Administrative Personnel 3 2014-01-01 2014-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  6. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 5 2014-07-01 2014-07-01 false Medical records. 701.122 Section 701.122... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... requirements of DOD 6025.18-R. (b) Disclosure. DON activities shall disclose medical records to the...

  7. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 5 Administrative Personnel 3 2012-01-01 2012-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  8. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 5 2013-07-01 2013-07-01 false Medical records. 701.122 Section 701.122... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... requirements of DOD 6025.18-R. (b) Disclosure. DON activities shall disclose medical records to the...

  9. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 5 Administrative Personnel 3 2011-01-01 2011-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  10. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... medical records. (1) A PACE organization must maintain a single, comprehensive medical record for each.... (7) Reports of contact with informal support (for example, caregiver, legal guardian, or next of kin... disclosure of personal information. (c) Transfer of medical records. The organization must promptly...

  11. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  12. Clinicians’ Evaluation of Computer-Assisted Medication Summarization of Electronic Medical Records

    PubMed Central

    Zhu, Xinxin; Cimin, James J.

    2014-01-01

    Each year thousands of patients die of avoidable medication errors. When a patient is admitted to, transferred within, or discharged from a clinical facility, clinicians should review previous medication orders, current orders and future plans for care, and reconcile differences if there are any. If medication reconciliation is not accurate and systematic, medication errors such as omissions, duplications, dosing errors, or drug interactions may occur and cause harm. Computer-assisted medication applications showed promise as an intervention to reduce medication summarization inaccuracies and thus avoidable medication errors. In this study, a computer-assisted medication summarization application, designed to abstract and represent multi-source time-oriented medication data, was introduced to assist clinicians with their medication reconciliation processes. An evaluation study was carried out to assess clinical usefulness and analyze potential impact of such application. Both quantitative and qualitative methods were applied to measure clinicians' performance efficiency and inaccuracy in medication summarization process with and without the intervention of computer-assisted medication application. Clinicians' feedback indicated the feasibility of integrating such a medication summarization tool into clinical practice workflow as a complementary addition to existing electronic health record systems. The result of the study showed potential to improve efficiency and reduce inaccuracy in clinician performance of medication summarization, which could in turn improve care efficiency, quality of care, and patient safety. PMID:24393492

  13. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 14 Aeronautics and Space 2 2011-01-01 2011-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  14. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 22 Foreign Relations 2 2014-04-01 2014-04-01 false Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  15. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 14 Aeronautics and Space 2 2012-01-01 2012-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  16. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 14 Aeronautics and Space 2 2014-01-01 2014-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  17. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 14 Aeronautics and Space 2 2013-01-01 2013-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  18. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 22 Foreign Relations 2 2011-04-01 2009-04-01 true Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  19. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 22 Foreign Relations 2 2010-04-01 2010-04-01 true Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  20. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 22 Foreign Relations 2 2012-04-01 2009-04-01 true Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  1. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 22 Foreign Relations 2 2013-04-01 2009-04-01 true Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  2. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 21 Food and Drugs 1 2010-04-01 2010-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an... in lieu of the procedures in paragraph (b)(1), that are not inconsistent with § 21.41(f)....

  3. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 21 Food and Drugs 1 2013-04-01 2013-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an... in lieu of the procedures in paragraph (b)(1), that are not inconsistent with § 21.41(f)....

  4. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 21 Food and Drugs 1 2012-04-01 2012-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an... in lieu of the procedures in paragraph (b)(1), that are not inconsistent with § 21.41(f)....

  5. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 21 Food and Drugs 1 2014-04-01 2014-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an... in lieu of the procedures in paragraph (b)(1), that are not inconsistent with § 21.41(f)....

  6. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 21 Food and Drugs 1 2011-04-01 2011-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an... in lieu of the procedures in paragraph (b)(1), that are not inconsistent with § 21.41(f)....

  7. Implementation of electronic medical records

    PubMed Central

    Greiver, Michelle; Barnsley, Jan; Glazier, Richard H.; Moineddin, Rahim; Harvey, Bart J.

    2011-01-01

    Abstract Objective To apply the diffusion-of-innovations theory to the examination of factors that are perceived by family physicians as influencing the implementation of electronic medical records (EMRs). Design Qualitative study with 2 focus groups 18 months after EMR implementation; participants also took part in a concurrent quantitative study examining EMR implementation and preventive services. Setting Toronto, Ont. Participants Twelve community-based family physicians. Methods We employed a semistructured interview guide. The interviews were audiotaped and transcribed verbatim; 2 researchers independently categorized and coded the transcripts and then met to compare and contrast their findings, category mapping, and interpretations. Findings were then mapped to an existing theoretical framework. Main findings Multiple barriers to EMR implementation were described. These included lack of relative advantage for many processes, high complexity of the system, low compatibility with physician needs and past experiences, difficulty with adaptation of the EMR to the organization and adaptation of the organization to the EMR, and lack of organizational slack. Positive factors were the presence of a champion and relative advantages for some processes. Conclusion Early EMR implementation experience is consistent with theoretical concepts associated with implementation of innovations. A problematic implementation process helps to explain, at least in part, the lack of improvement in preventive services in our quantitative results. PMID:21998247

  8. Performance analysis of a medical record exchanges model.

    PubMed

    Huang, Ean-Wen; Liou, Der-Ming

    2007-03-01

    Electronic medical record exchange among hospitals can provide more information for physician diagnosis and reduce costs from duplicate examinations. In this paper, we proposed and implemented a medical record exchange model. According to our study, exchange interface servers (EISs) are designed for hospitals to manage the information communication through the intra and interhospital networks linked with a medical records database. An index service center can be given responsibility for managing the EIS and publishing the addresses and public keys. The prototype system has been implemented to generate, parse, and transfer the health level seven query messages. Moreover, the system can encrypt and decrypt a message using the public-key encryption algorithm. The queuing theory is applied to evaluate the performance of our proposed model. We estimated the service time for each queue of the CPU, database, and network, and measured the response time and possible bottlenecks of the model. The capacity of the model is estimated to process the medical records of about 4000 patients/h in the 1-MB network backbone environments, which comprises about the 4% of the total outpatients in Taiwan.

  9. Double trouble: medical implications of genetic duplication and amplification in bacteria.

    PubMed

    Craven, Sarah H; Neidle, Ellen L

    2007-06-01

    Gene amplification allows organisms to adapt to changing environmental conditions. This type of increased gene dosage confers selectable benefits, typically by augmenting protein production. Gene amplification is a reversible process that does not require permanent genetic change. Although transient, altered gene dosage has significant medical impact. Recent examples of amplification in bacteria, described here, affect human disease by modifying antibiotic resistance, the virulence of pathogens, vaccine efficacy and antibiotic biosynthesis. Amplification is usually a two-step process whereby genetic duplication (step one) promotes further increases in copy number (step two). Both steps have important evolutionary significance for the emergence of innovative gene functions. Recent genome sequence analyses illustrate how genome plasticity can affect the evolution and immunogenic properties of bacterial pathogens.

  10. [Patients' access to their medical records].

    PubMed

    Laranjo, Liliana; Neves, Ana Luisa; Villanueva, Tiago; Cruz, Jorge; Brito de Sá, Armando; Sakellarides, Constantitno

    2013-01-01

    Until recently, the medical record was seen exclusively as being the property of health institutions and doctors. Its great technical and scientific components, as well as the personal characteristics attributed by each doctor, have been the reasons appointed for that control. However, nowadays throughout the world that paradigm has been changing. In Portugal, since 2007 patients are allowed full and direct access to their medical records. Nevertheless, the Deontological Code of the Portuguese Medical Association (2009) explicitly states that patients' access to their medical records should have a doctor as intermediary and that the records are each physician's intellectual property. Furthermore, several doctors and health institutions, receiving requests from patients to access their medical records, end up requesting the legal opinion of the Commission for access to administrative documents. Each and every time, that opinion goes in line with the notion of full and direct patient access. Sharing medical records with patients seems crucial and inevitable in the current patient-centred care model, having the potential to improve patient empowerment, health literacy, autonomy, self-efficacy and satisfaction with care. With the recent technological developments and the fast dissemination of Personal Health Records, it is foreseeable that a growing number of patients will want to access their medical records. Therefore, promoting awareness on this topic is essential, in order to allow an informed debate between all the stakeholders.

  11. Automation of the Problem Oriented Medical Record

    NASA Technical Reports Server (NTRS)

    Schall, D. W.

    1971-01-01

    An improved ambulatory care delivery system developed for the Navy is examined. The system is centered around the concepts of problem oriented medical records and expanded use of paramedical personnel.

  12. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... subject to which they pertain. However, if it is determined that such access could have an adverse effect upon the individual's physical or mental health, the medical record in question will be released...

  13. Ethics of medical records and professional communications.

    PubMed

    Recupero, Patricia R

    2008-01-01

    In child and adolescent psychiatry, medical records and professional communications raise important ethical concerns for the treating or consulting clinician. Although a distinction may be drawn between internal records (eg, medical records and psychotherapy notes) and external communications (eg, consultation reports and correspondence with pediatricians), several ethical principles apply to both types of documentation; however, specific considerations may vary, depending upon the context in which the records or communications were produced. Special care is due with regard to thoroughness and honesty, collaboration and cooperation, autonomy and dignity of the patient, confidentiality of the patient and family members, maintaining objectivity and neutrality, electronic communications media, and professional activities (eg, political advocacy). This article reviews relevant ethical concerns for child and adolescent psychiatrists with respect to medical records and professional communications, drawing heavily from forensic and legal sources, and offers additional recommendations for further reading for clarification and direction on ethical dilemmas.

  14. Linking medical records to an expert system

    NASA Technical Reports Server (NTRS)

    Naeymi-Rad, Frank; Trace, David; Desouzaalmeida, Fabio

    1991-01-01

    This presentation will be done using the IMR-Entry (Intelligent Medical Record Entry) system. IMR-Entry is a software program developed as a front-end to our diagnostic consultant software MEDAS (Medical Emergency Decision Assistance System). MEDAS (the Medical Emergency Diagnostic Assistance System) is a diagnostic consultant system using a multimembership Bayesian design for its inference engine and relational database technology for its knowledge base maintenance. Research on MEDAS began at the University of Southern California and the Institute of Critical Care in the mid 1970's with support from NASA and NSF. The MEDAS project moved to Chicago in 1982; its current progress is due to collaboration between Illinois Institute of Technology, The Chicago Medical School, Lake Forest College and NASA at KSC. Since the purpose of an expert system is to derive a hypothesis, its communication vocabulary is limited to features used by its knowledge base. The development of a comprehensive problem based medical record entry system which could handshake with an expert system while creating an electronic medical record at the same time was studied. IMR-E is a computer based patient record that serves as a front end to the expert system MEDAS. IMR-E is a graphically oriented comprehensive medical record. The programs major components are demonstrated.

  15. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2010-07-01 2010-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care Benefits for Certain Children of Vietnam Veterans-Spina Bifida and Covered Birth Defects § 17.905...

  16. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2011-07-01 2011-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea-Spina...

  17. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2014-07-01 2014-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea-Spina...

  18. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2012-07-01 2012-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea-Spina...

  19. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2013-07-01 2013-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea-Spina...

  20. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... have an adverse effect on the mental or physical health of the individual. Normally, this determination... practitioner. If it is medically indicated that access could have an adverse mental or physical effect on the... located may afford special protection to certain medical records (e.g., drug and alcohol abuse...

  1. Electronic medical record: Time to migrate?

    PubMed Central

    Rustagi, Neeti; Singh, Ritesh

    2012-01-01

    Gone are the days when records of patients were kept in paper format. Majority of things going digital, it is inevitable that hospitals will adopt electronic medical record in near future. It is simple, reliable and cost effective in long term. PMID:23293762

  2. Electronic medical record: Time to migrate?

    PubMed

    Rustagi, Neeti; Singh, Ritesh

    2012-10-01

    Gone are the days when records of patients were kept in paper format. Majority of things going digital, it is inevitable that hospitals will adopt electronic medical record in near future. It is simple, reliable and cost effective in long term.

  3. 3 Steps to Building a Personal Medical Record

    MedlinePlus

    ... Building a Personal Medical Record Print to PDF 3 Steps to Building a Personal Medical Record August ... forms or make phone calls for you. Step 3. Organizing and storing your personal medical record There ...

  4. Virtual medical scribes: making electronic medical records work for you.

    PubMed

    Brady, Kevin; Shariff, Afser

    2013-01-01

    There is increasing buzz around the term "medical scribe" in healthcare today. Medical scribes help meet the growing electronic medical record (EMR) data entry challenge healthcare providers face. Medical scribes reduce providers' paperwork burden, increase a medical practice's net margins, and reduce stress levels for doctors and their staff. They do this by charting patient encounters in real-time during patient examinations, thus reducing significantly the data entry workload that EMRs place on providers. Medical scribes can work onsite or offsite from a HIPAA-secure location, the latter being known as "virtual medical scribes." This article explores the uses and benefits of scribes to give you the background to employ them effectively in your clinic or hospital.

  5. Privacy, confidentiality, and electronic medical records.

    PubMed Central

    Barrows, R C; Clayton, P D

    1996-01-01

    The enhanced availability of health information in an electronic format is strategic for industry-wide efforts to improve the quality and reduce the cost of health care, yet it brings a concomitant concern of greater risk for loss of privacy among health care participants. The authors review the conflicting goals of accessibility and security for electronic medical records and discuss nontechnical and technical aspects that constitute a reasonable security solution. It is argued that with guiding policy and current technology, an electronic medical record may offer better security than a traditional paper record. PMID:8653450

  6. [Theo van Gogh's medical record].

    PubMed

    Voskuil, P H

    1992-09-01

    In the final months of his life Theo van Gogh was admitted to the 'Geneeskundig Gesticht voor Krankzinnigen te Utrecht'. In November 1990 from the archives of the Willem Arntsz Huis, psychiatric centre in Utrecht, the medical files from this period were made available and a transcription was made by Han van Crimpen and Sjraar van Heugten, scientific collaborators of the Van Gogh Museum. From these data it is acceptable to conclude that Theo van Gogh had dementia paralytica and suffered a fast deterioration of his situation in these last few months. It is, however, probable that at least as early as 1886 Theo showed the first symptoms of this disease when he was in Paris, and that he was treated for this reason by dr. Rivet and dr. Gruby. There are insufficient indications that in Vincent van Gogh's case the same diagnosis can be put forward. It is most probable that during Vincent's visit to Theo in Paris in July 1890 in Theo's case symptoms of his medical deterioration were to be seen and this may have influenced the considerations finally leading to Vincent van Gogh's suicide.

  7. Medical Terminology of the Musculoskeletal System. Medical Records. Instructional Unit for the Medical Transcriber.

    ERIC Educational Resources Information Center

    Gosman, Minna L.

    Following an analysis of the task of transcribing as practiced in a health facility, this study guide was developed to teach the knowledge and skills required of a medical transcriber. The medical record department was identified as a major occupational area, and a task inventory for medical records was developed and used as a basis for a…

  8. Medical Terminology of the Circulatory System. Medical Records. Instructional Unit for the Medical Transcriber.

    ERIC Educational Resources Information Center

    Gosman, Minna L.

    Developed as a result of an analysis of the task of transcribing as practiced in a health facility, this study guide was designed to teach the knowledge and skills required of a medical transcriber. The medical record department was identified as a major occupational area, and a task inventory for medical records was developed and used as a basis…

  9. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 37 Patents, Trademarks, and Copyrights 1 2012-07-01 2012-07-01 false Special procedures: Medical... Special procedures: Medical records. (a) No response to any request for access to medical records by an... routine use, for all systems of records containing medical records, consultations with an...

  10. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Medical magnetic tape recorder. 870.2800 Section... (CONTINUED) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Monitoring Devices § 870.2800 Medical magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  11. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 37 Patents, Trademarks, and Copyrights 1 2014-07-01 2014-07-01 false Special procedures: Medical... Special procedures: Medical records. (a) No response to any request for access to medical records by an... routine use, for all systems of records containing medical records, consultations with an...

  12. 20 CFR 401.55 - Access to medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false Access to medical records. 401.55 Section 401... INFORMATION The Privacy Act § 401.55 Access to medical records. (a) General. You have a right to access your medical records, including any psychological information that we maintain. (b) Medical records...

  13. Auditing medical records helps reduce liability.

    PubMed

    Ganguli, G; Winfrey, S

    1990-10-01

    An internal audit of a hospital's medical records department compares the department to standards developed by the hospital and to benchmarks set by accrediting organizations. An auditor can review the department's economy and effectiveness through employee surveys, direct observation, and interviews. By uncovering deficiencies and making recommendations for their correction, an internal audit can help limit a hospital's liability exposure.

  14. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on... information to a medical doctor named by the requesting individual for release of the patient....

  15. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on... information to a medical doctor named by the requesting individual for release of the patient....

  16. [Nurse's coworking to electronic medical record].

    PubMed

    Maresca, M; Gavaciuto, D; Cappelli, G

    2007-01-01

    Nephrologists need to register and look at a great number of clinical data. The use of electronic medical records may improve efficiency and reduce errors. Aim of our work is to report the experience of Villa Scassi Hospital in Genoa, where a "patient file" has been performed to improve nephrology practice management. The file contains all clinical records, laboratory and radiology data, therapy, dialysis clinics, in addition to reports of out-patients department. This system allowed a better efficiency in diagnosis and treatment of the patient. Moreover experience of nurses in employing electronic medical records is reported. A reduced number of errors was found in therapy administering, because of a only one data source for physicians and nurses. PMID:17922451

  17. Recent perspectives of electronic medical record systems

    PubMed Central

    ZHANG, XIAO-YING; ZHANG, PEIYING

    2016-01-01

    Implementation of electronic medical record (EMR) systems within developing contexts as part of efforts to monitor and facilitate the attainment of health-related aims has been on the increase. However, these efforts have been concentrated on urban hospitals. Recent findings showed that development processes of EMR systems are associated with various discrepancies between protocols and work practices. These discrepancies were mainly caused by factors including high workload, lack of medical resources, misunderstanding of the protocols by health workers, and client/patient practices. The present review focused on the effects of EMRs on patient care work, and on appropriate EMR designs principles and strategies to ameliorate these systems. PMID:27284289

  18. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 4 2010-01-01 2010-01-01 false Special procedures: Medical records. 310.6... PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on... transmission of the medical information directly to the requesting individual could have an adverse effect...

  19. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 5 2012-01-01 2012-01-01 false Special procedures: Medical records. 310.6... PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on... transmission of the medical information directly to the requesting individual could have an adverse effect...

  20. Electronic medical records in clinical teaching.

    PubMed

    Warboys, Ina; Mok, Wai Yin; Frith, Karen H

    2014-01-01

    The purpose of the project was to provide students with experiences to develop their technology competency and examine student perceptions about an academic electronic medical record (EMR) as a learning tool. Nurse educators need to integrate EMRs into their curricula to give students practice in the use of electronic documentation and retrieval of clinical information. The findings of this study indicated that students' use of EMRs at least 5 times resulted in the development of positive perceptions about their EMR experience. PMID:25073041

  1. 7 CFR 1.115 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 7 Agriculture 1 2013-01-01 2013-01-01 false Special procedures: Medical records. 1.115 Section 1... Regulations § 1.115 Special procedures: Medical records. In the event an agency receives a request pursuant to § 1.112 for access to medical records (including psychological records) whose disclosure it...

  2. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ...-medical records. 1301.16 Section 1301.16 Conservation of Power and Water Resources TENNESSEE VALLEY AUTHORITY PROCEDURES Privacy Act § 1301.16 Special procedures—medical records. If, in the judgment of TVA, the transmission of medical records, including psychological records, directly to a...

  3. 5 CFR 297.205 - Access to medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 5 Administrative Personnel 1 2013-01-01 2013-01-01 false Access to medical records. 297.205... PROCEDURES FOR PERSONNEL RECORDS Request for Access § 297.205 Access to medical records. When a request for access involves medical or psychological records that the system manager believes requires...

  4. 7 CFR 1.115 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 7 Agriculture 1 2014-01-01 2014-01-01 false Special procedures: Medical records. 1.115 Section 1... Regulations § 1.115 Special procedures: Medical records. In the event an agency receives a request pursuant to § 1.112 for access to medical records (including psychological records) whose disclosure it...

  5. 40 CFR 16.8 - Special procedures: Medical Records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 40 Protection of Environment 1 2014-07-01 2014-07-01 false Special procedures: Medical Records. 16... PRIVACY ACT OF 1974 § 16.8 Special procedures: Medical Records. Should EPA receive a request for access to medical records (including psychological records) disclosure of which the system manager decides would...

  6. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ...-medical records. 1301.16 Section 1301.16 Conservation of Power and Water Resources TENNESSEE VALLEY AUTHORITY PROCEDURES Privacy Act § 1301.16 Special procedures—medical records. If, in the judgment of TVA, the transmission of medical records, including psychological records, directly to a...

  7. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 29 Labor 4 2012-07-01 2012-07-01 false Special procedures: Medical records. 1611.6 Section 1611.6... REGULATIONS § 1611.6 Special procedures: Medical records. In the event the Commission receives a request pursuant to § 1611.3 for access to medical records (including psychological records) whose disclosure...

  8. 5 CFR 297.205 - Access to medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 5 Administrative Personnel 1 2011-01-01 2011-01-01 false Access to medical records. 297.205... PROCEDURES FOR PERSONNEL RECORDS Request for Access § 297.205 Access to medical records. When a request for access involves medical or psychological records that the system manager believes requires...

  9. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 29 Labor 4 2011-07-01 2011-07-01 false Special procedures: Medical records. 1611.6 Section 1611.6... REGULATIONS § 1611.6 Special procedures: Medical records. In the event the Commission receives a request pursuant to § 1611.3 for access to medical records (including psychological records) whose disclosure...

  10. 7 CFR 1.115 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 7 Agriculture 1 2010-01-01 2010-01-01 false Special procedures: Medical records. 1.115 Section 1... Regulations § 1.115 Special procedures: Medical records. In the event an agency receives a request pursuant to § 1.112 for access to medical records (including psychological records) whose disclosure it...

  11. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ...-medical records. 1301.16 Section 1301.16 Conservation of Power and Water Resources TENNESSEE VALLEY AUTHORITY PROCEDURES Privacy Act § 1301.16 Special procedures—medical records. If, in the judgment of TVA, the transmission of medical records, including psychological records, directly to a...

  12. 40 CFR 16.8 - Special procedures: Medical Records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 40 Protection of Environment 1 2010-07-01 2010-07-01 false Special procedures: Medical Records. 16... PRIVACY ACT OF 1974 § 16.8 Special procedures: Medical Records. Should EPA receive a request for access to medical records (including psychological records) disclosure of which the system manager decides would...

  13. 40 CFR 16.8 - Special procedures: Medical Records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 40 Protection of Environment 1 2013-07-01 2013-07-01 false Special procedures: Medical Records. 16... PRIVACY ACT OF 1974 § 16.8 Special procedures: Medical Records. Should EPA receive a request for access to medical records (including psychological records) disclosure of which the system manager decides would...

  14. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 29 Labor 4 2014-07-01 2014-07-01 false Special procedures: Medical records. 1611.6 Section 1611.6... REGULATIONS § 1611.6 Special procedures: Medical records. In the event the Commission receives a request pursuant to § 1611.3 for access to medical records (including psychological records) whose disclosure...

  15. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... routine use, for all systems of records containing medical records, consultations with an individual's... record to USPTO's medical expert for review and a determination on whether consultation with or... be warranted, USPTO's medical expert shall so consult or transmit. Whether or not such a...

  16. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 5 Administrative Personnel 3 2013-01-01 2013-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  17. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 2 2011-07-01 2011-07-01 false Special procedures: Medical records. 319.7... (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures: Medical records. Medical records, requested pursuant to § 319.5 of this part, will be disclosed to the...

  18. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ...: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An individual requesting disclosure of a record which contains medical or psychological information may name a...

  19. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 15 Commerce and Foreign Trade 1 2010-01-01 2010-01-01 false Special procedures: Medical records. 4... GOVERNMENT INFORMATION Privacy Act § 4.26 Special procedures: Medical records. (a) No response to any request for access to medical records from an individual will be issued by the Privacy Officer for a period...

  20. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 15 Commerce and Foreign Trade 1 2013-01-01 2013-01-01 false Special procedures: Medical records. 4... GOVERNMENT INFORMATION Privacy Act § 4.26 Special procedures: Medical records. (a) No response to any request for access to medical records from an individual will be issued by the Privacy Officer for a period...

  1. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ...: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An individual requesting disclosure of a record which contains medical or psychological information may name a...

  2. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 29 Labor 4 2012-07-01 2012-07-01 false Special procedures: Medical records. 1410.5 Section 1410.5 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE PRIVACY § 1410.5 Special procedures: Medical records. (a) If medical records are requested for inspection...

  3. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 5 Administrative Personnel 3 2012-01-01 2012-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  4. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 2 2013-07-01 2013-07-01 false Special procedures: Medical records. 319.7... (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures: Medical records. Medical records, requested pursuant to § 319.5 of this part, will be disclosed to the...

  5. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ...: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An individual requesting disclosure of a record which contains medical or psychological information may name a...

  6. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 15 Commerce and Foreign Trade 1 2014-01-01 2014-01-01 false Special procedures: Medical records. 4... GOVERNMENT INFORMATION Privacy Act § 4.26 Special procedures: Medical records. (a) No response to any request for access to medical records from an individual will be issued by the Privacy Officer for a period...

  7. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 29 Labor 4 2011-07-01 2011-07-01 false Special procedures: Medical records. 1410.5 Section 1410.5 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE PRIVACY § 1410.5 Special procedures: Medical records. (a) If medical records are requested for inspection...

  8. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  9. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Records of mobile medical services. 35.2080 Section 35.2080 Energy NUCLEAR REGULATORY COMMISSION MEDICAL USE OF BYPRODUCT MATERIAL Records § 35.2080 Records of mobile medical services. (a) A licensee shall retain a copy of each letter that permits the use of byproduct material at a client's address,...

  10. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 10 Energy 1 2013-01-01 2013-01-01 false Records of mobile medical services. 35.2080 Section 35.2080 Energy NUCLEAR REGULATORY COMMISSION MEDICAL USE OF BYPRODUCT MATERIAL Records § 35.2080 Records of mobile medical services. (a) A licensee shall retain a copy of each letter that permits the use of byproduct material at a client's address,...

  11. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 37 Patents, Trademarks, and Copyrights 1 2011-07-01 2011-07-01 false Special procedures: Medical records. 102.26 Section 102.26 Patents, Trademarks, and Copyrights UNITED STATES PATENT AND TRADEMARK... Special procedures: Medical records. (a) No response to any request for access to medical records by...

  12. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 12 Banks and Banking 5 2013-01-01 2013-01-01 false Special procedures: Medical records. 310.6 Section 310.6 Banks and Banking FEDERAL DEPOSIT INSURANCE CORPORATION PROCEDURE AND RULES OF PRACTICE PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on request to the individuals to whom...

  13. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 5 Administrative Personnel 3 2014-01-01 2014-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  14. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 29 Labor 4 2014-07-01 2014-07-01 false Special procedures: Medical records. 1410.5 Section 1410.5 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE PRIVACY § 1410.5 Special procedures: Medical records. (a) If medical records are requested for inspection...

  15. Essentials of an Acceptable School for Medical Record Technicians.

    ERIC Educational Resources Information Center

    American Medical Association, Chicago, IL. Council on Medical Education.

    The Council on Medical Education of the American Medical Association in collaboration with the American Association of Medical Record Librarians establishes standards for medical record technician education, surveys and approves educational programs, and publishes lists of approved programs. The standards presented are intended as a guide for…

  16. A benchmark comparison of deterministic and probabilistic methods for defining manual review datasets in duplicate records reconciliation

    PubMed Central

    Joffe, Erel; Byrne, Michael J; Reeder, Phillip; Herskovic, Jorge R; Johnson, Craig W; McCoy, Allison B; Sittig, Dean F; Bernstam, Elmer V

    2014-01-01

    Introduction Clinical databases require accurate entity resolution (ER). One approach is to use algorithms that assign questionable cases to manual review. Few studies have compared the performance of common algorithms for such a task. Furthermore, previous work has been limited by a lack of objective methods for setting algorithm parameters. We compared the performance of common ER algorithms: using algorithmic optimization, rather than manual parameter tuning, and on two-threshold classification (match/manual review/non-match) as well as single-threshold (match/non-match). Methods We manually reviewed 20 000 randomly selected, potential duplicate record-pairs to identify matches (10 000 training set, 10 000 test set). We evaluated the probabilistic expectation maximization, simple deterministic and fuzzy inference engine (FIE) algorithms. We used particle swarm to optimize algorithm parameters for a single and for two thresholds. We ran 10 iterations of optimization using the training set and report averaged performance against the test set. Results The overall estimated duplicate rate was 6%. FIE and simple deterministic algorithms allowed a lower manual review set compared to the probabilistic method (FIE 1.9%, simple deterministic 2.5%, probabilistic 3.6%; p<0.001). For a single threshold, the simple deterministic algorithm performed better than the probabilistic method (positive predictive value 0.956 vs 0.887, sensitivity 0.985 vs 0.887, p<0.001). ER with FIE classifies 98.1% of record-pairs correctly (1/10 000 error rate), assigning the remainder to manual review. Conclusions Optimized deterministic algorithms outperform the probabilistic method. There is a strong case for considering optimized deterministic methods for ER. PMID:23703827

  17. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Medical magnetic tape recorder. 870.2800 Section 870.2800 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES... magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  18. Transaction recording in medical image processing

    NASA Astrophysics Data System (ADS)

    Riedel, Christian H.; Ploeger, Andreas; Onnasch, Dietrich G. W.; Mehdorn, Hubertus M.

    1999-07-01

    In medical image processing original image data on archive servers may absolutely not be modified directly. On the other hand, images from read-only devices like CD-ROM cannot be changed and saved on the same storage medium. In both cases the modified data have to be stored as a second version and large amounts of storage volume are needed. We avoid these problems by using a program which records only each transaction prescribed to images. Each transaction is stored and used for further utilization and for renewed submission of the modified data. Conventionally, every time an image is viewed or printed, the modified version has to be saved in addition to the recorded data, either automatically or by the user. Compared to these approaches which not only squander storage space but area also time consuming our program has the following and advantages: First, the original image data which may not be modified are protected against manipulation. Second, small amounts of storage volume and network range are needed. Third, approved image operations can be automated by macros derived from transaction recordings. Finally, operations on the original data can always be controlled and traced back. As the handling of images gets easier with this concept, security for original image data is granted.

  19. Impact of an electronic medication administration record on medication administration efficiency and errors.

    PubMed

    McComas, Jeffery; Riingen, Michelle; Chae Kim, Son

    2014-12-01

    The study aims were to evaluate the impact of electronic medication administration record implementation on medication administration efficiency and occurrence of medication errors as well as to identify the predictors of medication administration efficiency in an acute care setting. A prospective, observational study utilizing time-and-motion technique was conducted before and after electronic medication administration record implementation in November 2011. A total of 156 cases of medication administration activities (78 pre- and 78 post-electronic medication administration record) involving 38 nurses were observed at the point of care. A separate retrospective review of the hospital Midas+ medication error database was also performed to collect the rates and origin of medication errors for 6 months before and after electronic medication administration record implementation. The mean medication administration time actually increased from 11.3 to 14.4 minutes post-electronic medication administration record (P = .039). In a multivariate analysis, electronic medication administration record was not a predictor of medication administration time, but the distractions/interruptions during medication administration process were significant predictors. The mean hospital-wide medication errors significantly decreased from 11.0 to 5.3 events per month post-electronic medication administration record (P = .034). Although no improvement in medication administration efficiency was observed, electronic medication administration record improved the quality of care with a significant decrease in medication errors.

  20. Video Recording Paper - Innovation In Medical Video Recording

    NASA Astrophysics Data System (ADS)

    Shalit, Hanoch

    1985-09-01

    Traditionally, multiple format recording emulsions for medical video imaging have utilized a film (transparent) base. The major reason for this is probably because the film and camera manufacturers felt the diagnostician is accustomed to viewing x-ray images on a film base and would prefer to view video images that way also. Because of the need to keep radiation exposure to patients at a minimum and the fact that photographic emulsions are generally very inefficient in utilizing x-ray radiation, a film base was the logical requirement for direct x-ray imaging as it enabled the image to be recorded by two emulsions rather than one. The transparent base thus allows viewing a photograph which is the result of the additive effect of the two emulsions. The use of transparent base imposed specific requirements that necessitated the development of a whole complex of equipment designed for the particular use of film such as the processing machines, their chemical solutions, and the famous viewbox and alternators that characterize the radiology departments of today.

  1. Progress in electronic medical record adoption in Canada

    PubMed Central

    Chang, Feng; Gupta, Nishi

    2015-01-01

    Objective To determine the rate of adoption of electronic medical records (EMRs) by physicians across Canada, provincial incentives, and perceived benefits of and barriers to EMR adoption. Data sources Data on EMR adoption in Canada were collected from CINAHL, MEDLINE, PubMed, EMBASE, the Cochrane Library, the Health Council of Canada, Canada Health Infoway, government websites, regional EMR associations, and health professional association websites. Study selection After removal of duplicate articles, 236 documents were found matching the original search. After using the filter Canada, 12 documents remained. Additional documents were obtained from each province’s EMR website and from the Canada Health Infoway website. Synthesis Since 2006, Canadian EMR adoption rates have increased from about 20% of practitioners to an estimated 62% of practitioners in 2013, with substantial regional disparities ranging from roughly 40% of physicians in New Brunswick and Quebec to more than 75% of physicians in Alberta. Provincial incentives vary widely but appear to have only a weak relationship with the rate of adoption. Many adopters use only a fraction of their software’s available functions. User-cited benefits to adoption include time savings, improved record keeping, heightened patient safety, and confidence in retrieved data when EMRs are used efficiently. Barriers to adoption include financial and time constraints, lack of knowledgeable support personnel, and lack of interoperability with hospital and pharmacy systems. Conclusion Canadian physicians remain at the stage of EMR adoption. Progression in EMR use requires experienced, knowledgeable technical support during implementation, and financial support for the transcription of patient data from paper to electronic media. The interoperability of EMR offerings for hospitals, pharmacies, and clinics is the rate-limiting factor in achieving a unified EMR solution for Canada. PMID:27035020

  2. 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

  3. 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

  4. Perspectives on electronic medical records adoption: electronic medical records (EMR) in outcomes research.

    PubMed

    Belletti, Dan; Zacker, Christopher; Mullins, C Daniel

    2010-07-01

    Health information technology (HIT) is engineered to promote improved quality and efficiency of care, and reduce medical errors. Healthcare organizations have made significant investments in HIT tools and the electronic medical record (EMR) is a major technological advance. The Department of Veterans Affairs was one of the first large healthcare systems to fully implement EMR. The Veterans Health Information System and Technology Architecture (VistA) began by providing an interface to review and update a patient's medical record with its computerized patient record system. However, since the implementation of the VistA system there has not been an overall substantial adoption of EMR in the ambulatory or inpatient setting. In fact, only 23.9% of physicians were using EMRs in their office-based practices in 2005. A sample from the American Medical Association revealed that EMRs were available in an office setting to 17% of physicians in late 2007 and early 2008. Of these, 17% of physicians with EMR, only 4% were considered to be fully functional EMR systems. With the exception of some large aggregate EMR databases the slow adoption of EMR has limited its use in outcomes research. This paper reviews the literature and presents the current status of and forces influencing the adoption of EMR in the office-based practice, and identifies the benefits, limitations, and overall value of EMR in the conduct of outcomes research in the US.

  5. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 19 Customs Duties 3 2011-04-01 2011-04-01 false Special procedures: Medical records. 201.27... APPLICATION Safeguarding Individual Privacy Pursuant to 5 U.S.C. 552a § 201.27 Special procedures: Medical... maintained by the Commission which pertain to him or her, medical and psychological records merit...

  6. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 19 Customs Duties 3 2010-04-01 2010-04-01 false Special procedures: Medical records. 201.27... APPLICATION Safeguarding Individual Privacy Pursuant to 5 U.S.C. 552a § 201.27 Special procedures: Medical... maintained by the Commission which pertain to him or her, medical and psychological records merit...

  7. 28 CFR 513.42 - Inmate access to medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Inmate access to medical records. 513.42... ADMINISTRATION ACCESS TO RECORDS Release of Information Inmate Requests to Institution for Information § 513.42 Inmate access to medical records. (a) Except for the limitations of paragraphs (c) and (d) of...

  8. 28 CFR 513.42 - Inmate access to medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Inmate access to medical records. 513.42... ADMINISTRATION ACCESS TO RECORDS Release of Information Inmate Requests to Institution for Information § 513.42 Inmate access to medical records. (a) Except for the limitations of paragraphs (c) and (d) of...

  9. 28 CFR 513.42 - Inmate access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Inmate access to medical records. 513.42... ADMINISTRATION ACCESS TO RECORDS Release of Information Inmate Requests to Institution for Information § 513.42 Inmate access to medical records. (a) Except for the limitations of paragraphs (c) and (d) of...

  10. 28 CFR 513.42 - Inmate access to medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Inmate access to medical records. 513.42... ADMINISTRATION ACCESS TO RECORDS Release of Information Inmate Requests to Institution for Information § 513.42 Inmate access to medical records. (a) Except for the limitations of paragraphs (c) and (d) of...

  11. 28 CFR 513.42 - Inmate access to medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 28 Judicial Administration 2 2011-07-01 2011-07-01 false Inmate access to medical records. 513.42... ADMINISTRATION ACCESS TO RECORDS Release of Information Inmate Requests to Institution for Information § 513.42 Inmate access to medical records. (a) Except for the limitations of paragraphs (c) and (d) of...

  12. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020;...

  13. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020;...

  14. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020;...

  15. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020;...

  16. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020;...

  17. Report of the Task Force on Medical Record Education. American Medical Record Association.

    PubMed

    1986-12-01

    An eight-member task force on medical record education was created in 1985 as part of AMRA's strategic planning process and long history of commitment to education. This report on their activities was presented to the Board of Directors in September 1986. While not intended to be a definitive work plan, the recommendations in the report involve the entire AMRA membership. The task force expects and encourages extensive debate on the issues and recommendations contained herein.

  18. 44 CFR 6.31 - Special requirements for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., DEPARTMENT OF HOMELAND SECURITY GENERAL IMPLEMENTATION OF THE PRIVACY ACT OF 1974 Individual Access to... Personnel Management and are described in Chapter 339, Federal Personnel Manual (medical records...

  19. Centralised versus decentralised management of patients' medical records.

    PubMed

    Quantin, Catherine; Coatrieux, Gouenou; Fassa, Maniane; Breton, Vincent; Jaquet-Chiffelle, David-Olivier; de Vlieger, Paul; Lypszyc, Norbert; Boire, Jean-Yves; Roux, Christian; Allaert, François-André

    2009-01-01

    For more than 20 years, many countries have been trying to set up a standardised medical record at the regional or at the national level. Most of them have not reached this goal, essentially due to two main difficulties related to patient identification and medical records standardisation. Moreover, the issues raised by the centralisation of all gathered medical data have to be tackled particularly in terms of security and privacy. We discuss here the interest of a non-centralised management of medical records which would require a specific procedure that gives to the patient access to his/her distributed medical data, wherever he/she is located.

  20. Medical records department and balanced scorecard approach

    PubMed Central

    Ajami, Sima; Ebadsichani, Afsaneh; Tofighi, Shahram; Tavakoli, Nahid

    2013-01-01

    Context: The Medical Records Department (MRD) is an important source for evaluating and planning of healthcare services; therefore, hospital managers should improve their performance not only in the short-term but also in the long-term plans. The Balanced Scorecard (BSC) is a tool in the management system that enables organizations to correct operational functions and provides feedback around both the internal processes and the external outcomes, in order to improve strategic performance and outcomes continuously. Aims: The main goal of this study was to assess the MRD performance with BSC approach in a hospital. Materials and Methods: This research was an analytical cross-sectional study in which data was collected by questionnaires, forms and observation. The population was the staff of the MRD in a hospital in Najafabad, Isfahan, Iran. Statistical Analysis Used: To analyze data, first, objectives of the MRD, according to the mission and perspectives of the hospital, were redefined and, second, indicators were measured. Subsequently, findings from the performance were compared with the expected score. In order to achieve the final target, the programs, activities, and plans were reformed. Results: The MRD was successful in absorbing customer satisfaction. From a customer perspective, score in customer satisfaction of admission and statistics sections were 82% and 83%, respectively. Conclusions: The comprehensive nature of the strategy map makes the MRD especially useful as a consensus building and communication tool in the hospital. PMID:24083257

  1. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies...

  2. Medical records: practicalities and principles of patient possession.

    PubMed

    Gilhooly, M L; McGhee, S M

    1991-09-01

    This review of issues and research is in two parts: 1) practical problems surrounding patient-held records and 2) ethical arguments for and against patient-held records. We argue that research on patient-held records indicates that there are no substantial practical drawbacks and considerable ethical benefits to be derived from giving patients custody of their medical records.

  3. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... to the FAA; or (2) Authorize any clinic, hospital, physician, or other person to release to the FAA... medical certificate or, in the case of an applicant, deny the application for a medical certificate....

  4. 22 CFR 215.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 22 Foreign Relations 1 2014-04-01 2014-04-01 false Special procedures: Medical records. 215.6... PRIVACY ACT OF 1974 § 215.6 Special procedures: Medical records. If the Assistant Director for Administration or the Privacy Liaison Officer, determines that the release directly to the individual of...

  5. 22 CFR 215.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 22 Foreign Relations 1 2013-04-01 2013-04-01 false Special procedures: Medical records. 215.6... PRIVACY ACT OF 1974 § 215.6 Special procedures: Medical records. If the Assistant Director for Administration or the Privacy Liaison Officer, determines that the release directly to the individual of...

  6. 12 CFR 1403.6 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... Section 1403.6 Banks and Banking FARM CREDIT SYSTEM INSURANCE CORPORATION PRIVACY ACT REGULATIONS § 1403.6 Special procedures for medical records. Medical records in the custody of the Farm Credit System Insurance... the individual to whom they pertain or that person's authorized or legal representative or to...

  7. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 18 Conservation of Power and Water Resources 2 2011-04-01 2011-04-01 false Special procedure: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An...

  8. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 18 Conservation of Power and Water Resources 2 2010-04-01 2010-04-01 false Special procedure: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An...

  9. 22 CFR 215.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 22 Foreign Relations 1 2010-04-01 2010-04-01 false Special procedures: Medical records. 215.6... PRIVACY ACT OF 1974 § 215.6 Special procedures: Medical records. If the Assistant Director for Administration or the Privacy Liaison Officer, determines that the release directly to the individual of...

  10. Technology Acceptance of Electronic Medical Records by Nurses

    ERIC Educational Resources Information Center

    Stocker, Gary

    2010-01-01

    The purpose of this study was to evaluate the Technology Acceptance Model's (TAM) relevance of the intention of nurses to use electronic medical records in acute health care settings. The basic technology acceptance research of Davis (1989) was applied to the specific technology tool of electronic medical records (EMR) in a specific setting…

  11. [Duodenal duplication].

    PubMed

    Ilari, J; Martorell, R; Morales, M; Capdevila, M; Mairal, J A; Teixidó, M; Casadellá, A

    1998-01-01

    Cystic duplication of the duodenum is a rare anomaly of the gastrointestinal tract. This is a report of a newborn with a cystic duplication of duodenum diagnosed prenatally. It's relevant the few clinical symptoms of a such big mass. The surgical procedure was excision of the cyst, with a good post operative curse. PMID:9662869

  12. Study of Screen Design Principles for Visualizing Medical Records.

    PubMed

    Fujita, Kenichiro; Takemura, Tadamasa; Kuroda, Tomohiro

    2015-01-01

    To improve UX of EMR/EHR, the screen design principles for the visualization are required. Through the study of common attributes of medical records, we present four principles and show three screen designs by applying them.

  13. Medical record review for clinical pertinence.

    PubMed

    Lewis, K S

    1991-08-01

    This clinical pertinence review process described was in effect for seven months, after which the author terminated affiliation with the hospital. Despite resistance by many physicians, this monthly review process focused the medical staff's attention on good documentation practices. To the author's knowledge, the plan is still in use.

  14. SOAP to SNOCAMP: improving the medical record format.

    PubMed

    Larimore, W L; Jordan, E V

    1995-10-01

    Not since the development of the SOAP note in the problem-oriented medical record has there been a significant need to alter the format of medical record documentation. With the intrusion of third-party audits, malpractice attorney subpoenas, medical guidelines, and reimbursement code criteria into the practice of medicine, there is a need to expand the traditional SOAP note. This article proposes a new acronym, "SNOCAMP," for medical record documentation. SNOCAMP retains the SOAP format, which includes subjective, objective, assessment, and plan of treatment, with the addition of nature of the presenting complaint, counseling, and medical decision-making. It is hoped that this new, more explicit format will prove successful in meeting the divergent needs of practicing physicians, the patients they serve, and the inquiring minds that look over their shoulders.

  15. The New World of Interaction Recording for Medical Practices.

    PubMed

    Levy, Michael

    2016-01-01

    Today's medical practice staff communicates remotely with patients, pharmacies, and other medical providers in new ways that go far beyond telephone calls. Patient care and communication are now being provided via telecommunications technologies, including chat/IM, screen, Skype, and other video applications. This new paradigm in patient care, known as "telehealth" or "telemedicine," could put medical practices at risk for noncompliance with strict HIPAA and other regulations. Interaction recording encompasses these new means of communication and can help medical practice staff achieve compliance and reduce financial and liability risks while improving operations and patient care. This article explores what medical practices need to know about interaction recording, what to look for in an interaction recording solution, and how to best utilize that solution to meet compliance, manage liability, and improve patient care. PMID:27039643

  16. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY UNITED STATES NAVY REGULATIONS..., observing the following procedures: (1) In the United States, the laws of the State where the records are... statutes may apply. (2) For installations located outside the United States, the custodial parent or...

  17. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY UNITED STATES NAVY REGULATIONS..., observing the following procedures: (1) In the United States, the laws of the State where the records are... statutes may apply. (2) For installations located outside the United States, the custodial parent or...

  18. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Medical magnetic tape recorder. 870.2800 Section 870.2800 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Monitoring Devices § 870.2800...

  19. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health... or a mental health professional indicating that, in his or her opinion, disclosure of the requested...) Designation of physician or mental health professional to receive records. If the ASC believes, in good...

  20. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health... or a mental health professional indicating that, in his or her opinion, disclosure of the requested...) Designation of physician or mental health professional to receive records. If the ASC believes, in good...

  1. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health... or a mental health professional indicating that, in his or her opinion, disclosure of the requested...) Designation of physician or mental health professional to receive records. If the ASC believes, in good...

  2. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health... or a mental health professional indicating that, in his or her opinion, disclosure of the requested...) Designation of physician or mental health professional to receive records. If the ASC believes, in good...

  3. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health... or a mental health professional indicating that, in his or her opinion, disclosure of the requested...) Designation of physician or mental health professional to receive records. If the ASC believes, in good...

  4. Electronic Medical Records and Their Impact on Resident and Medical Student Education

    ERIC Educational Resources Information Center

    Keenan, Craig R.; Nguyen, Hien H.; Srinivasan, Malathi

    2006-01-01

    Objective: Electronic medical records (EMRs) are becoming prevalent and integral tools for residents and medical students. EMRs can integrate point-of-service information delivery within the context of patient care. Though it may be an educational tool, little is known about how EMR technology is currently used for medical learners. Method: The…

  5. Privacy, confidentiality, privilege, and the medical record. Part I.

    PubMed

    Hoyt, E M

    1986-08-01

    For thousands of years physicians have recorded clinical observations as private notes to document the clinical course, findings, and treatment of their patients. The medical record was generated exclusively for the physician's use in treating the patient. Physicians and hospitals are now under extraordinary pressure to reveal patient information. During the past 20 years, the role of the medical record has changed and it now has become a multipurpose document. Health care records are the topic of reports, interviews and depositions. Controlled disclosure of the sensitive information contained in the record is essential in today's society yet, when such information is released, various considerations must be carefully evaluated and weighed. From his vantage point as a physician and attorney, the author shares his insight and his concerns about privacy, confidentiality and privilege as related to health records in this two part article.

  6. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... Program’ (see 32 CFR part 310). ... 32 National Defense 2 2011-07-01 2011-07-01 false Access to medical and psychological records. 324... to medical and psychological records. Individual access to medical and psychological records...

  7. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... Program’ (see 32 CFR part 310). ... 32 National Defense 2 2010-07-01 2010-07-01 false Access to medical and psychological records. 324... to medical and psychological records. Individual access to medical and psychological records...

  8. Should a patient have access to his medical records.

    PubMed

    de Klerk, A

    1989-01-01

    An investigation is undertaken into the right of a patient to have access to medical records concerning himself, and the ownership of medical records and X-ray photographs is discussed. It is argued that record accessibility by patients is to favoured. The current situation in England and the United States of America is considered and proposals de lege ferenda are made with respect to South Africa. The author is of the opinion that the South African legislature should consider legislation in this regard.

  9. Recent developments in electronic medical records.

    PubMed

    Worth, E R

    1998-05-01

    Human factors engineering principles will guide the development of future EMR systems. Physicians will use wireless palmtop computers to record patient data so that the computer does not come between the physician and patient in routine encounters. With few exceptions, the pieces for this type of system are available today, but not in one package. I believe EMR developers have recognized the ubiquity and power of the Internet. Because of advances in computers, software, and telecommunications reliability, solutions using thin-client technology will lower the cost of EMRs to physicians. PMID:9604665

  10. Medical Record Clerk Training Program, Course of Study; Student Manual: For Medical Record Personnel in Small Rural Hospitals in Colorado.

    ERIC Educational Resources Information Center

    Community Health Service (DHEW/PHS), Arlington, VA. Div. of Health Resources.

    The manual provides major topics, objectives, activities and, procedures, references and materials, and assignments for the training program. The topics covered are hospital organization and community role, organization and management of a medical records department, international classification of diseases and operations, medical terminology,…

  11. Effectiveness of an electronic inpatient medication record in reducing medication errors in Singapore.

    PubMed

    Choo, Janet; Johnston, Linda; Manias, Elizabeth

    2014-06-01

    This study examined the effectiveness of an inpatient electronic medication record system in reducing medication errors in Singaporean hospitals. This pre- and post-intervention study involving a control group was undertaken in two Singaporean acute care hospitals. In one hospital the inpatient electronic medication record system was implemented while in another hospital the paper-based medication record system was used. The mean incidence difference in medication errors of 0.06 between pre-intervention (0.72 per 1000 patient days) and post-intervention (0.78 per 1000 patient days) for the two hospitals was not statistically significant (95%, CI: [0.26, 0.20]). The mean incidence differences in medication errors relating to prescription, dispensing, and administration were also not statistically different. Common system failures involved a lack of medication knowledge by health professionals and a lack of a systematic approach in identifying correct dosages. There was no difference in the incidence of medication errors following the introduction of the electronic medication record system. More work is needed on how this system can reduce medication error rates and improve medication safety.

  12. Computerized medical records: the need for a standard.

    PubMed

    Bradbury, A

    1990-03-01

    Major concepts introduced in this paper are as follows. 1) Organization, with its attendant qualities of accuracy, consistency, legibility, completeness, and simplicity, is the heart of the medical record. Technology should not be allowed to obscure this goal. 2) The main function of the computerized medical record is data storage with the qualities of organization noted above. This function must be clearly separated from condensation, analysis, or other secondary manipulation of data. 3) Many aspects of data manipulation call for the judgment of a physician. This judgement may be aided by computer software, but not replaced by it. 4) Present technological barriers, most notably speed, permanent large storage, and voice input should not influence the design of the effective computerized record. Future technology will be able to service the carefully designed medical record. 5) Textual parts of the computerized medical record can follow a simple and machine independent outline format. All parts of the record should use a textual introduction emphasizing patient and record identification. 6) A patient profile is central to each patient file. Updating this profile as needed must be recognized as a primary function of the physician at every patient encounter. 7) Acceptance of a standard for the computerized medical record now, before technology has matured and software diversified, will avoid a pitfall commonly experienced in other fields and save substantial healthcare funds. This standard should be geared to the needs of physicians and patients, not to the constraints of technology. The future of medical computing is bright. Obstacles to the practical use of the computerized medical record exist, but we may expect these to vanish within a few years. The great challenge to physicians now is to take this opportunity to control a new technology, rather than to be driven by it. The soul of good medicine is not in the equipment available, but in the rational and carefully

  13. Building Structured Personal Health Records from Photographs of Printed Medical Records

    PubMed Central

    Li, Xiang; Hu, Gang; Teng, Xiaofei; Xie, Guotong

    2015-01-01

    Personal health records (PHRs) provide patient-centric healthcare by making health records accessible to patients. In China, it is very difficult for individuals to access electronic health records. Instead, individuals can easily obtain the printed copies of their own medical records, such as prescriptions and lab test reports, from hospitals. In this paper, we propose a practical approach to extract structured data from printed medical records photographed by mobile phones. An optical character recognition (OCR) pipeline is performed to recognize text in a document photo, which addresses the problems of low image quality and content complexity by image pre-processing and multiple OCR engine synthesis. A series of annotation algorithms that support flexible layouts are then used to identify the document type, entities of interest, and entity correlations, from which a structured PHR document is built. The proposed approach was applied to real world medical records to demonstrate the effectiveness and applicability. PMID:26958219

  14. How to manage secure direct access of European patients to their computerized medical record and personal medical record.

    PubMed

    Quantin, Catherine; Allaert, François André; Fassa, Maniane; Riandey, Benoît; Avillach, Paul; Cohen, Olivier

    2007-01-01

    The multiplication of the requests of the patients for a direct access to their Medical Record (MR), the development of Personal Medical Record (PMR) supervised by the patients themselves, the increasing development of the patients' electronic medical records (EMRs) and the world wide internet utilization will lead to envisage an access by using technical automatic and scientific way. It will require the addition of different conditions: a unique patient identifier which could base on a familial component in order to get access to the right record anywhere in Europe, very strict identity checks using cryptographic techniques such as those for the electronic signature, which will ensure the authentication of the requests sender and the integrity of the file but also the protection of the confidentiality and the access follow up. The electronic medical record must also be electronically signed by the practitioner in order to get evidence that he has given his agreement and taken the liability for that. This electronic signature also avoids any kind of post-transmission falsification. This will become extremely important, especially in France where patients will have the possibility to mask information that, they do not want to appear in their personal medical record. Currently, the idea of every citizen having electronic signatures available appears positively Utopian. But this is yet the case in eGovernment, eHealth and eShopping, world-wide. The same was thought about smart cards before they became generally available and useful when banks issued them.

  15. How to choose an electronic medical record.

    PubMed

    Lanier, Bob G

    2006-01-01

    I chose a Windows-based file system over a server-based system with a proprietary database, or a web-based system which has both a proprietary database and which also required a full time Internet connection. My reasoning was that I found it uncomplicated. I was familiar with the Windows interface and it required little effort to enter my existing data and was simple to operate the system. If one laptop crashes, my other computers still work. I don't fear failure of an Internet connection source, a modem or a server, power surges or other possible single points of failure that might prevent my patient care. I can incorporate all document types, I can update jump drives with any needed medical information. I can share information instantly with other systems. I can store my own data in a flexible and open format. I have no maintenance contract and I can make changes in my system or can even change vendors at any time. Last but certainly not least, I do not need a highly trained technical staff to operate or maintain our system.

  16. THE QUANTITATIVE STUDY OF THE FACULTY MEMBERS PERFORMANCE IN DOCUMENTATION OF THE MEDICAL RECORDS IN TEACHING HOSPITALS OF MAZANDARAN UNIVERSITY OF MEDICAL SCIENCES

    PubMed Central

    Asghari, Zolaykha; Mardanshahi, Alireza; Farahabadi, Ebrahim Bagherian; Siamian, Hasan; Gorji, Ali Morad Heidari; Saravi, Benyamin Mohseni; Rezazadeh, Esmaeil; Paymard, Seyyed Payam

    2016-01-01

    rate was in a poor level, more attempt should be made to achieve a better condition. Even if a data element of the sheets seems meaningless, unnecessary and duplicated, it should not be ignored and skipped. In order to solve such problems, it is suggested that medical records sheets and the elements that seem unnecessary, should be reviewed in relevant committees.

  17. The medical record entrepreneur: a future of opportunities.

    PubMed

    Dietz, M S; Nath, D D

    1989-06-01

    In summary, medical record practitioners can become successful entrepreneurs with the right motivation. It will be important to overcome the fear and inertia inherent in any bold new venture, to find our "niche," to assume the roles of explorer, artist, judge, and champion, as well as to encourage and promote our development within an organization or in a business of our own. Medical record entrepreneurs need to evaluate and understand current and potential consumers, their current needs, perceptions, and future needs. Entrepreneurs should capitalize on strengths, develop innovative marketing approaches, and apply them. In the current climate of the health care industry, there is a myriad of entrepreneurial opportunities available to the medical record profession. It all begins with the individual.

  18. Real and imagined barriers to an electronic medical record.

    PubMed

    Rind, D M; Safran, C

    1993-01-01

    We developed an electronic medical record for ambulatory patients as part of the integrated clinical information system at Beth Israel Hospital. During the four years since it was installed, clinicians have entered 76,060 patient problems, 137,713 medications, and 33,938 notes. Residents, who had to type notes in themselves, entered 49.5% of their notes into OMR. Several factors that we had predicted would be barriers to an electronic medical record, such as clinician reluctance to type or perform data entry, have not proved to be significant problems. Other anticipated barriers, such as difficulties with dual charting on paper during transition to an electronic medical record, have been realized. The major unexpected barrier that has been encountered is increased clinician concern about the privacy and security of full text notes relative to other data elements in the clinical information system. We have attempted to modify the electronic medical record so as to overcome some of these barriers. PMID:8130574

  19. Information integrity and privacy for computerized medical patient records

    SciTech Connect

    Gallegos, J.; Hamilton, V.; Gaylor, T.; McCurley, K.; Meeks, T.

    1996-09-01

    Sandia National Laboratories and Oceania, Inc. entered into a Cooperative Research and Development Agreement (CRADA) in November 1993 to provide ``Information Integrity and Privacy for Computerized Medical Patient Records`` (CRADA No. SC93/01183). The main objective of the project was to develop information protection methods that are appropriate for databases of patient records in health information systems. This document describes the findings and alternative solutions that resulted from this CRADA.

  20. Are In-Bed Electronic Weights Recorded in the Medical Record Accurate?

    PubMed

    Gerl, Heather; Miko, Alexandra; Nelson, Mandy; Godaire, Lori

    2016-01-01

    This study found large discrepancies between in-bed weights recorded in the medical record and carefully obtained standing weights with a calibrated, electronic bedside scale. This discrepancy appears to be related to inadequate bed calibration before patient admission and having excessive linen, clothing, and/or equipment on the bed during weighing by caregivers. PMID:27522846

  1. Carrying their own medical records: the perspective of pregnant women.

    PubMed

    Phipps, H

    2001-11-01

    Freedom of information, access to and ownership of medical records are current and controversial issues in Australia. Relating to pregnancy and birth the debate provokes emotional responses and raises important questions about access to information, decision-making, responsibility, power and control. The aim of this qualitative study was to explore the impact on pregnant women of carrying their medical records throughout pregnancy Twenty-one women participated in face-to-face individual interviews, which were coded for thematic analysis. The study found the reaction of women toward carrying their own records to be overwhelmingly positive. Maternal record holding had the potential to improve the level of communication between the health care worker and the pregnant woman and provided a greater sense of sharing and communication within the family The study also established that maternal record holding was of benefit to the woman's partner who was better informed and more involved in the pregnancy All but one of the women who participated favoured carrying their records in subsequent pregnancies. A concern about the potential for losing or misplacing records was not seen in this study, as no women lost their records. A sense of ownership would argue against this possible drawback.

  2. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 2 2014-07-01 2014-07-01 false Special procedures: Medical records. 319.7 Section 319.7 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures:...

  3. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 2 2012-07-01 2012-07-01 false Special procedures: Medical records. 319.7 Section 319.7 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures:...

  4. Evaluation of a Lecture Recording System in a Medical Curriculum

    ERIC Educational Resources Information Center

    Bacro, Thierry R. H.; Gebregziabher, Mulugeta; Fitzharris, Timothy P.

    2010-01-01

    Recently, the Medical University of South Carolina adopted a lecture recording system (LRS). A retrospective study of LRS was implemented to document the students' perceptions, pattern of usage, and impact on the students' grades in three basic sciences courses (Cell Biology/Histology, Physiology, and Neurosciences). The number of accesses and…

  5. Who owns the information in the medical record? Copyright issues.

    PubMed

    Mair, Judith

    2011-01-01

    As part of every private healthcare practice and healthcare facility, documentation of patients' healthcare, diagnoses and treatment are an ongoing requirement with legal connotations. The question that may arise is whether copyright can subsist in patient medical records, and if so, what benefit may arise from ownership of such copyright.

  6. Sharing electronic medical records across multiple heterogeneous and competing institutions.

    PubMed Central

    Kohane, I. S.; van Wingerde, F. J.; Fackler, J. C.; Cimino, C.; Kilbridge, P.; Murphy, S.; Chueh, H.; Rind, D.; Safran, C.; Barnett, O.; Szolovits, P.

    1996-01-01

    Most early reports of implemented World-Wide Web (W3) medical record systems describe single institution architectures. We describe W3-EMRS, a multi-institutional architecture, and its implementation. Thorny problems in data sharing underlined by the W3-EMRS project are reviewed. PMID:8947738

  7. Biobanks and Electronic Medical Records: Enabling Cost-Effective Research

    PubMed Central

    Bowton, Erica; Field, Julie R.; Wang, Sunny; Schildcrout, Jonathan S.; Van Driest, Sara L.; Delaney, Jessica T.; Cowan, James; Weeke, Peter; Mosley, Jonathan D.; Wells, Quinn S.; Karnes, Jason H.; Shaffer, Christian; Peterson, Josh F.; Denny, Joshua C.; Roden, Dan M.; Pulley, Jill M.

    2014-01-01

    The use of electronic medical record data linked to biological specimens in health care settings is expected to enable cost-effective and rapid genomic analyses. Here, we present a model that highlights potential advantages for genomic discovery and describe the operational infrastructure that facilitated multiple simultaneous discovery efforts. PMID:24786321

  8. Physician Sensemaking and Readiness for Electronic Medical Records

    ERIC Educational Resources Information Center

    Riesenmy, Kelly Rouse

    2010-01-01

    Purpose: The purpose of this paper is to explore physician sensemaking and readiness to implement electronic medical records (EMR) as a first step to finding strategies that enhance EMR adoption behaviors. Design/methodology/approach: The case study approach provides a detailed analysis of individuals within an organizational unit. Using a…

  9. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Special procedures: Medical records. 319.7 Section 319.7 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures:...

  10. Privacy preserving index for encrypted electronic medical records.

    PubMed

    Chen, Yu-Chi; Horng, Gwoboa; Lin, Yi-Jheng; Chen, Kuo-Chang

    2013-12-01

    With the development of electronic systems, privacy has become an important security issue in real-life. In medical systems, privacy of patients' electronic medical records (EMRs) must be fully protected. However, to combine the efficiency and privacy, privacy preserving index is introduced to preserve the privacy, where the EMR can be efficiently accessed by this patient or specific doctor. In the literature, Goh first proposed a secure index scheme with keyword search over encrypted data based on a well-known primitive, Bloom filter. In this paper, we propose a new privacy preserving index scheme, called position index (P-index), with keyword search over the encrypted data. The proposed index scheme is semantically secure against the adaptive chosen keyword attack, and it also provides flexible space, lower false positive rate, and search privacy. Moreover, it does not rely on pairing, a complicate computation, and thus can search over encrypted electronic medical records from the cloud server efficiently.

  11. A Codasyl-Type Schema for Natural Language Medical Records

    PubMed Central

    Sager, N.; Tick, L.; Story, G.; Hirschman, L.

    1980-01-01

    This paper describes a CODASYL (network) database schema for information derived from narrative clinical reports. The goal of this work is to create an automated process that accepts natural language documents as input and maps this information into a database of a type managed by existing database management systems. The schema described here represents the medical events and facts identified through the natural language processing. This processing decomposes each narrative into a set of elementary assertions, represented as MEDFACT records in the database. Each assertion in turn consists of a subject and a predicate classed according to a limited number of medical event types, e.g., signs/symptoms, laboratory tests, etc. The subject and predicate are represented by EVENT records which are owned by the MEDFACT record associated with the assertion. The CODASYL-type network structure was found to be suitable for expressing most of the relations needed to represent the natural language information. However, special mechanisms were developed for storing the time relations between EVENT records and for recording connections (such as causality) between certain MEDFACT records. This schema has been implemented using the UNIVAC DMS-1100 DBMS.

  12. How Patients Can Improve the Accuracy of their Medical Records

    PubMed Central

    Dullabh, Prashila M.; Sondheimer, Norman K.; Katsh, Ethan; Evans, Michael A.

    2014-01-01

    Objectives: Assess (1) if patients can improve their medical records’ accuracy if effectively engaged using a networked Personal Health Record; (2) workflow efficiency and reliability for receiving and processing patient feedback; and (3) patient feedback’s impact on medical record accuracy. Background: Improving medical record’ accuracy and associated challenges have been documented extensively. Providing patients with useful access to their records through information technology gives them new opportunities to improve their records’ accuracy and completeness. A new approach supporting online contributions to their medication lists by patients of Geisinger Health Systems, an online patient-engagement advocate, revealed this can be done successfully. In late 2011, Geisinger launched an online process for patients to provide electronic feedback on their medication lists’ accuracy before a doctor visit. Patient feedback was routed to a Geisinger pharmacist, who reviewed it and followed up with the patient before changing the medication list shared by the patient and the clinicians. Methods: The evaluation employed mixed methods and consisted of patient focus groups (users, nonusers, and partial users of the feedback form), semi structured interviews with providers and pharmacists, user observations with patients, and quantitative analysis of patient feedback data and pharmacists’ medication reconciliation logs. Findings/Discussion: (1) Patients were eager to provide feedback on their medications and saw numerous advantages. Thirty percent of patient feedback forms (457 of 1,500) were completed and submitted to Geisinger. Patients requested changes to the shared medication lists in 89 percent of cases (369 of 414 forms). These included frequency—or dosage changes to existing prescriptions and requests for new medications (prescriptions and over-the counter). (2) Patients provided useful and accurate online feedback. In a subsample of 107 forms

  13. Medical record: systematic centralization versus secure on demand aggregation

    PubMed Central

    2011-01-01

    Background As patients often see the data of their medical histories scattered among various medical records hosted in several health-care establishments, the purpose of our multidisciplinary study was to define a pragmatic and secure on-demand based system able to gather this information, with no risk of breaching confidentiality, and to relay it to a medical professional who asked for the information via a specific search engine. Methods Scattered data are often heterogeneous, which makes the task of gathering information very hard. Two methods can be compared: trying to solve the problem by standardizing and centralizing all the information about every patient in a single Medical Record system or trying to use the data "as is" and find a way to obtain the most complete and the most accurate information. Given the failure of the first approach, due to the lack of standardization or privacy and security problems, for example, we propose an alternative that relies on the current state of affairs: an on-demand system, using a specific search engine that is able to retrieve information from the different medical records of a single patient. Results We describe the function of Medical Record Search Engines (MRSE), which are able to retrieve all the available information regarding a patient who has been hospitalized in different hospitals and to provide this information to health professionals upon request. MRSEs use pseudonymized patient identities and thus never have access to the patient's identity. However, though the system would be easy to implement as it by-passes many of the difficulties associated with a centralized architecture, the health professional would have to validate the information, i.e. read all of the information and create his own synthesis and possibly reject extra data, which could be a drawback. We thus propose various feasible improvements, based on the implementation of several tools in our on-demand based system. Conclusions A system that

  14. 36 CFR 1238.16 - What are the microfilming requirements for temporary records, duplicates, and user copies?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... noted in § 1238.3, and manufacturer's instructions for processing production, and maintenance of microform to ensure that the images are accessible and usable for the entire retention period of the records....

  15. 36 CFR 1238.16 - What are the microfilming requirements for temporary records, duplicates, and user copies?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... noted in § 1238.3, and manufacturer's instructions for processing production, and maintenance of microform to ensure that the images are accessible and usable for the entire retention period of the records....

  16. Data-Driven Information Extraction from Chinese Electronic Medical Records

    PubMed Central

    Zhao, Tianwan; Ge, Chen; Gao, Weiguo; Wei, Jia; Zhu, Kenny Q.

    2015-01-01

    Objective This study aims to propose a data-driven framework that takes unstructured free text narratives in Chinese Electronic Medical Records (EMRs) as input and converts them into structured time-event-description triples, where the description is either an elaboration or an outcome of the medical event. Materials and Methods Our framework uses a hybrid approach. It consists of constructing cross-domain core medical lexica, an unsupervised, iterative algorithm to accrue more accurate terms into the lexica, rules to address Chinese writing conventions and temporal descriptors, and a Support Vector Machine (SVM) algorithm that innovatively utilizes Normalized Google Distance (NGD) to estimate the correlation between medical events and their descriptions. Results The effectiveness of the framework was demonstrated with a dataset of 24,817 de-identified Chinese EMRs. The cross-domain medical lexica were capable of recognizing terms with an F1-score of 0.896. 98.5% of recorded medical events were linked to temporal descriptors. The NGD SVM description-event matching achieved an F1-score of 0.874. The end-to-end time-event-description extraction of our framework achieved an F1-score of 0.846. Discussion In terms of named entity recognition, the proposed framework outperforms state-of-the-art supervised learning algorithms (F1-score: 0.896 vs. 0.886). In event-description association, the NGD SVM is superior to SVM using only local context and semantic features (F1-score: 0.874 vs. 0.838). Conclusions The framework is data-driven, weakly supervised, and robust against the variations and noises that tend to occur in a large corpus. It addresses Chinese medical writing conventions and variations in writing styles through patterns used for discovering new terms and rules for updating the lexica. PMID:26295801

  17. National electronic medical records integration on cloud computing system.

    PubMed

    Mirza, Hebah; El-Masri, Samir

    2013-01-01

    Few Healthcare providers have an advanced level of Electronic Medical Record (EMR) adoption. Others have a low level and most have no EMR at all. Cloud computing technology is a new emerging technology that has been used in other industry and showed a great success. Despite the great features of Cloud computing, they haven't been utilized fairly yet in healthcare industry. This study presents an innovative Healthcare Cloud Computing system for Integrating Electronic Health Record (EHR). The proposed Cloud system applies the Cloud Computing technology on EHR system, to present a comprehensive EHR integrated environment.

  18. National electronic medical records integration on cloud computing system.

    PubMed

    Mirza, Hebah; El-Masri, Samir

    2013-01-01

    Few Healthcare providers have an advanced level of Electronic Medical Record (EMR) adoption. Others have a low level and most have no EMR at all. Cloud computing technology is a new emerging technology that has been used in other industry and showed a great success. Despite the great features of Cloud computing, they haven't been utilized fairly yet in healthcare industry. This study presents an innovative Healthcare Cloud Computing system for Integrating Electronic Health Record (EHR). The proposed Cloud system applies the Cloud Computing technology on EHR system, to present a comprehensive EHR integrated environment. PMID:23920993

  19. The search for the elusive electronic medical record system--medical liability, the missing factor.

    PubMed

    Grams, R R; Moyer, E H

    1997-02-01

    Over the past few years, the traditional paper-based medical record system has come under close scrutiny by every participant in the healthcare industry. Some groups, especially federal agencies such as Medicare and Medicaid, HMOs, and other third party payors, have begun to demand changes in medical record documentation, and have become very assertive as to what goals and objectives will be met. In contrast, the medical liability insurance industry has remained almost invisible during this period of transition. At a recent electronic medical records (EMR) conference participants attending a software development workshop were asked if they had their systems reviewed from a medicolegal standpoint by a malpractice insurance carrier. In response to this inquiry, not one software vendor raised their hand to indicate this had been accomplished, or was even contemplated. In the author's opinion, the key missing factor in the current quest for a paperless medical office system rests in the domain of those who represent the medical liability industry. All of these gate-keepers of medical loss and risk prevention will eventually be called upon, either by choice or necessity, to validate every working EMR system that is used in medical practices in the future. This article will explore the best information published from this currently silent sector of the industry, and proposes an active involvement by the medical liability industry in the current EMR design and development processes taking place. In addition, there are 10 minimum EMR design criteria contained in this article that are recommended for implementation based upon 16 years of medical malpractice experience and loss prevention input.

  20. Efficient medical information retrieval in encrypted Electronic Health Records.

    PubMed

    Pruski, Cédric; Wisniewski, François

    2012-01-01

    The recent development of eHealth platforms across the world, whose main objective is to centralize patient's healthcare information to ensure the best continuity of care, requires the development of advanced tools and techniques for supporting health professionals in retrieving relevant information in this vast quantity of data. However, for preserving patient's privacy, some countries decided to de-identify and encrypt data contained in the shared Electronic Health Records, which reinforces the complexity of proposing efficient medical information retrieval approach. In this paper, we describe an original approach exploiting standards metadata as well as knowledge organizing systems to overcome the barriers of data encryption for improving the results of medical information retrieval in centralized and encrypted Electronic Health Records. This is done through the exploitation of semantic properties provided by knowledge organizing systems, which enable query expansion. Furthermore, we provide an overview of the approach together with illustrating examples and a discussion on the advantages and limitations of the provided framework.

  1. Task centered visualization of Electronic Medical Record flow sheet.

    PubMed

    Xie, Zhong; Gregg, Peggy; Zhang, Jiajie

    2003-01-01

    Usability problem of Electronic Medical Record (EMR) systems is a major hurdle for their acceptance. In this study we used the methodology of Human-Centered Distributed Information Design (HCDID) to compare and evaluate Flow Sheet module of two commercial EMR systems. After which we tried to develop usable interface of a flow sheet using visualization, focusing on task-representation mapping during design and development.

  2. Meta-modelling the Medical Record: Design and Application

    PubMed Central

    Huet, Bernard; Lesueur, Bruno; Lebeux, Pierre; Blain, Gilles

    2000-01-01

    This project is based on a user-oriented design for medical record, thanks to a meta-model able to generate various models for an application domain. The meta-model is constituted of basic concepts: User Semantic Group, sentence-type, variable, graph. A beginning of implementation is in echocardiography report; The advantages are a very thorough personalization of the document for the user, and a greater independence of the design diagram from the technological platform.

  3. Education and the medical record professional: obligation or opportunity?

    PubMed

    Barr, C J

    1988-12-01

    The present health care environment demands an emphasis on continuing education and the constant upgrading of ones' professional skills and abilities. The pressure to update and maintain skills can be a burden on the members of our profession, or it can pose exciting challenges to our creativity. This article discusses the career opportunities available to medical record professionals in the area of providing educational programs to other health care professionals, and some ways to take advantage of these opportunities.

  4. Lay people's experiences with reading their medical record.

    PubMed

    Wibe, Torunn; Hellesø, Ragnhild; Slaughter, Laura; Ekstedt, Mirjam

    2011-05-01

    An increasing number of patients now make use of their legal right to read their medical record. We report findings from a study in which we conducted qualitative interviews with 17 Norwegian adult patients about their experiences of requesting a copy of their medical record following a hospital stay. Interviews took place between May, 2008 and April 2009. The analytical process, guided by qualitative content analysis, identified two main themes; "keeping a sense of control" and "not feeling respected as a person". The informants' experiences with reading their own medical record were often connected to their experiences in direct communication with health care professionals during the hospital stay, revealing a delicate interaction between trust and power. The informants were hoping for a more mutual exchange of information and knowledge from which they could benefit in the management of their own health. We conclude that to meet patients' expectations of mutuality, health care professionals in hospitals need to be more conscious about their attitudes and communication skills as well as how they exercise their power to define the patient's situation. At the same time, there should be more focus on how structural changes in the organization of hospitals may have impaired the capacity of health care professionals to meet these expectations. In the future, greater attention should also be paid to information exchange to avoid placing unreasonable responsibility on the patient to compensate for deficits in the health care system.

  5. Recording and podcasting of lectures for students of medical school.

    PubMed

    Brunet, Pierre; Cuggia, Marc; Le Beux, Pierre

    2011-01-01

    Information and communication technology (ICT) becomes an important way for the knowledge transmission, especially in the field of medicine. Podcasting (mobile broadcast content) has recently emerged as an efficient tool for distributing information towards professionals, especially for e-learning contents.The goal of this work is to implement software and hardware tools for collecting medical lectures at its source by direct recording (halls and classrooms) and provide the automatic delivery of these resources for students on different type of devices (computer, smartphone or videogames console). We describe the overall architecture and the methods used by medical students to master this technology in their daily activities. We highlight the benefits and the limits of the Podcast technologies for medical education. PMID:21893751

  6. [Medical and pharmaceutical tales recorded in "Genroku- Sekenbanashi-Fubunshu"].

    PubMed

    Hamada, T

    1996-12-01

    "Genroku-Sekenbanashi-Fubunshu" consists of eleven volumes and was written from 1694 to 1703, in the Edo Period. The original book was kept at the Faculty of Literature, Tokyo University. In 1994, this book was first published as one of the Iwanami-Bunko Series. I studied the tales recorded in this book and found that twenty-seven of them were concerned with medical and pharmaceutial sciences. In these medical and pharmaceutical tales, there were several kinds, relating to such matters as spells to cure or prevent illness, curious sicknesses, episodes regarding the origin of remedies, medicinal plants and crude drugs, medical books, doctors and surgeons, persons who lived long, and so forth. It was difficult to explain about the spells which were thought effective to cure illness, but I could gain an understanding that Japanese people lived such lives in the old days. PMID:11619293

  7. The Regenstrief Medical Record System: a quarter century experience.

    PubMed

    McDonald, C J; Overhage, J M; Tierney, W M; Dexter, P R; Martin, D K; Suico, J G; Zafar, A; Schadow, G; Blevins, L; Glazener, T; Meeks-Johnson, J; Lemmon, L; Warvel, J; Porterfield, B; Warvel, J; Cassidy, P; Lindbergh, D; Belsito, A; Tucker, M; Williams, B; Wodniak, C

    1999-06-01

    Entrusted with the records for more than 1.5 million patients, the Regenstrief Medical Record System (RMRS) has evolved into a fast and comprehensive data repository used extensively at three hospitals on the Indiana University Medical Center campus and more than 30 Indianapolis clinics. The RMRS routinely captures laboratory results, narrative reports, orders, medications, radiology reports, registration information, nursing assessments, vital signs, EKGs and other clinical data. In this paper, we describe the RMRS data model, file structures and architecture, as well as recent necessary changes to these as we coordinate a collaborative effort among all major Indianapolis hospital systems, improving patient care by capturing city-wide laboratory and encounter data. We believe that our success represents persistent efforts to build interfaces directly to multiple independent instruments and other data collection systems, using medical standards such as HL7, LOINC, and DICOM. Inpatient and outpatient order entry systems, instruments for visit notes and on-line questionnaires that replace hardcopy forms, and intelligent use of coded data entry supplement the RMRS. Physicians happily enter orders, problems, allergies, visit notes, and discharge summaries into our locally developed Gopher order entry system, as we provide them with convenient output forms, choice lists, defaults, templates, reminders, drug interaction information, charge information, and on-line articles and textbooks. To prepare for the future, we have begun wrapping our system in Web browser technology, testing voice dictation and understanding, and employing wireless technology.

  8. Semantic models in medical record data-bases.

    PubMed

    Cerutti, S

    1980-01-01

    A great effort has been recently made in the area of data-base design in a number of application fields (banking, insurance, travel, etc.). Yet, it is the current experience of computer scientists in the medical field that medical record information-processing requires less rigid and more complete definition of data-base specifications for a much more heterogeneous set of data, for different users who have different aims. Hence, it is important to state that the data-base in the medical field ought to be a model of the environment for which it was created, rather than just a collection of data. New more powerful and more flexible data-base models are being now designed, particularly in the USA, where the current trend in medicine is to implement, in the same structure, the connection among more different and specific users and the data-base (for administrative aims, medical care control, treatments, statistical and epidemiological results, etc.). In such a way the single users are able to talk with the data-base without interfering with one another. The present paper outlines that this multi-purpose flexibility can be achieved by improving mainly the capabilities of the data-base model. This concept allows the creation of procedures of semantic integrity control which will certainly have in the future a dramatic impact on important management features, starting from data-quality checking and non-physiological state detections, as far as more medical-oriented procedures like drug interactions, record surveillance and medical care review. That is especially true when a large amount of data are to be processed and the classical hierarchical and network data models are no longer sufficient for developing satisfactory and reliable automatic procedures. In this regard, particular emphasis will be dedicated to the relational model and, at the highest level, to the same semantic data model.

  9. Five benefits of call recording for medical practices.

    PubMed

    Murphy, Roland

    2010-01-01

    Despite documentation's essential positioning in medical practices of all sizes and specialties, one aspect of patient and insurance provider interaction remains overlooked in the majority of practices: telephone-based communication. In many cases, patient and payment information exchanged via telephone is logged with little more than a note typed or written in the patient file. This leads to "he said/she said" disagreements with regard to patient service, consultations, and coding; reduced payments from insurance providers; incomplete patient records; liability exposure; and a host of other problems. In this article, call recording professional Roland Murphy explains how a call recording solution can fill the gaps in documentation, increase practice revenues, and improve patient care without excessive investment costs and while protecting patient confidentiality. PMID:20480782

  10. A Pharmacy Blueprint for Electronic Medical Record Implementation Success

    PubMed Central

    Bach, David S.; Risko, Kenneth R.; Farber, Margo S.; Polk, Gregory J.

    2015-01-01

    Objective: Implementation of an integrated, electronic medical record (EMR) has been promoted as a means of improving patient safety and quality. While there are a few reports of such processes that incorporate computerized prescriber order entry, pharmacy verification, an electronic medication administration record (eMAR), point-of-care barcode scanning, and clinical decision support, there are no published reports on how a pharmacy department can best participate in implementing such a process across a multihospital health care system. Method: This article relates the experience of the design, build, deployment, and maintenance of an integrated EMR solution from the pharmacy perspective. It describes a 9-month planning and build phase and the subsequent rollout at 8 hospitals over the following 13 months. Results: Key components to success are identified, as well as a set of guiding principles that proved invaluable in decision making and dispute resolution. Labor/personnel requirements for the various stages of the process are discussed, as are issues involving medication workflow analysis, drug database considerations, the development of clinical order sets, and incorporation of bar-code scanning of medications. Recommended implementation and maintenance strategies are presented, and the impact of EMR implementation on the pharmacy practice model and revenue analysis are examined. Conclusion: Adherence to the principles and practices outlined in this article can assist pharmacy administrators and clinicians during all medication-related phases of the development, implementation, and maintenance of an EMR solution. Furthermore, review and incorporation of some or all of practices presented may help ease the process and ensure its success. PMID:26405340

  11. Disciplined doctors: the electronic medical record and physicians' changing relationship to medical knowledge.

    PubMed

    Reich, Adam

    2012-04-01

    This study explores the effects of the electronic medical record (EMR) on the power of the medical profession. It is based on twenty-five in-depth interviews with administrators and physicians across three departments of a large, U.S. integrated health system, as well as ethnographic observation, all of which took place between September of 2009 and December of 2010. While scholarship on professional power has tended toward the opposite poles of professional dominance and deprofessionalization or proletarianization, I find that doctors' interactions with the EMR reconcile these perspectives by making physicians' professional identities consistent with their subordination to bureaucratic authority. After examining the electronic medical record as a disciplinary technology, the paper analyzes variation in the extent to which practitioners' professional identities are reconciled with bureaucratic subordination across the different departments studies.

  12. [Electronic medical records: medical and legal aspects, privacy, safety, and legal validity].

    PubMed

    Ravizza, P; Pasini, E

    2001-03-01

    Medical records must collect all data concerning in-hospital management of patients: data have to be verified and easily retrievable. Clinicians are responsible for both format and content of medical records. Respect of patient's privacy must be made sure both during on-line management and long-term storage of records. Computerization can offer many advantages to clinicians, but needs some significant adjustments: training and motivation of operators, arrangement of clinical processes and of administrative rules to technological developments. Nevertheless, some important results can be afforded: standardization of procedures, distribution of univocal, verified and ubiquitous data to all concerned operators, protection against undesired retrieval, reliability of effective reports. Preliminary condition is a clinical local area network, widespread into the institution. Database implementation must follow well accepted methodology: flow chart design of data dictionary, standardization of data coding, input of verified data, effective reporting. Access to data must be controlled by sophisticated and sure password system. Back-up of data must be automatically available with adequate timing and methodology. Respect of rules on patient's privacy must be realized whenever possible. Complex clinical records should be made available, containing data, signals and images (both single frames and dynamic sequences), due to continuous technical progress of diagnostic tools. Medical records must be available for long periods of time: database engine and managing tools must be selected among well accepted and largely available producers; informatic assistance must be assured for management and evolution of systems over the years.

  13. Use of electronic medical records in oncology outcomes research.

    PubMed

    Kanas, Gena; Morimoto, Libby; Mowat, Fionna; O'Malley, Cynthia; Fryzek, Jon; Nordyke, Robert

    2010-01-01

    Oncology outcomes research could benefit from the use of an oncology-specific electronic medical record (EMR) network. The benefits and challenges of using EMR in general health research have been investigated; however, the utility of EMR for oncology outcomes research has not been explored. Compared to current available oncology databases and registries, an oncology-specific EMR could provide comprehensive and accurate information on clinical diagnoses, personal and medical histories, planned and actual treatment regimens, and post-treatment outcomes, to address research questions from patients, policy makers, the pharmaceutical industry, and clinicians/researchers. Specific challenges related to structural (eg, interoperability, data format/entry), clinical (eg, maintenance and continuity of records, variety of coding schemes), and research-related (eg, missing data, generalizability, privacy) issues must be addressed when building an oncology-specific EMR system. Researchers should engage with medical professional groups to guide development of EMR systems that would ultimately help improve the quality of cancer care through oncology outcomes research.

  14. Reflecting on the ethical administration of computerized medical records

    NASA Astrophysics Data System (ADS)

    Collmann, Jeff R.

    1995-05-01

    This presentation examines the ethical issues raised by computerized image management and communication systems (IMAC), the ethical principals that should guide development of policies, procedures and practices for IMACS systems, and who should be involved in developing a hospital's approach to these issues. The ready access of computerized records creates special hazards of which hospitals must beware. Hospitals must maintain confidentiality of patient's records while making records available to authorized users as efficiently as possible. The general conditions of contemporary health care undermine protecting the confidentiality of patient record. Patients may not provide health care institutions with information about themselves under conditions of informed consent. The field of information science must design sophisticated systems of computer security that stratify access, create audit trails on data changes and system use, safeguard patient data from corruption, and protect the databases from outside invasion. Radiology professionals must both work with information science experts in their own hospitals to create institutional safeguards and include the adequacy of security measures as a criterion for evaluating PACS systems. New policies and procedures on maintaining computerized patient records must be developed that obligate all members of the health care staff, not just care givers. Patients must be informed about the existence of computerized medical records, the rules and practices that govern their dissemination and given the opportunity to give or withhold consent for their use. Departmental and hospital policies on confidentiality should be reviewed to determine if revisions are necessary to manage computer-based records. Well developed discussions of the ethical principles and administrative policies on confidentiality and informed consent and of the risks posed by computer-based patient records systems should be included in initial and continuing

  15. Cardiovascular disease documentation and counseling in electronic medical records.

    PubMed

    Bae, Jaeyong; Huerta, Timothy R; Ford, Eric W

    2016-07-01

    The purpose of this paper is to explore the relationship between clinical reminders generated by electronic medical record (EMR) systems and providers giving prevention counseling to patients at-risk for cardiovascular disease (CVD). Data were extracted from the 2012 National Ambulatory Medical Care Survey (NAMCS). Results indicate that the providers routinely using clinical reminders are significantly more likely to document height and weight data to determine risk and provide the recommended counseling to patients that merit the intervention. The findings are important for policymakers and managers that have been promoting the adoption of more sophisticated EMR decision support functionalities across the care delivery spectrum. In particular, the ability to intervene prior to negative health events is an important feature of the movement to improve care quality and reduce costs. PMID:27002255

  16. The University of Washington electronic medical record experience.

    PubMed

    Welton, Nanette J

    2010-07-01

    The Health Sciences Library at the University of Washington initiated and continues to develop a role in the electronic medical record, starting with the development of the first integrated web-based interface, called MINDscape. An Integrated Academic Information Management System (IAIMS) grant in 1992 began the process, which also led to the development of a clinical medical librarian position. Over the years, the librarian's role in the clinical environment became more established, and with the advent of clinical online resources, it offered further opportunities for librarians to provide the expertise needed to incorporate the appropriate resources. The collaborative journey continues as librarians, now able to directly access the EMRs, provide information about what resources to use and where best to place them and design how best to provide notes or feedback to clinicians.

  17. [Implementation of the shared medication record is difficult].

    PubMed

    Christensen, Selina; Jensen, Line Due; Kaae, Susanne; Vinding, Kirsten Laila; Petersen, Janne

    2014-07-21

    The aim of the study was to examine the implementation of the shared medication record (SMR) and the barriers to lack of implementation. The research was done in three hospitals in Denmark. Data showed that SMR was not used systematically in the period 5-19 March 2012 at a hospital in the Capital Region of Denmark. We found that motivation, technical problems, time, and competencies were barriers to using SMR. Although all the doctors liked the idea of SMR, they did not find the present version of SMR to be fully developed for use in practice.

  18. Application of an Electronic Medical Record in Space Medicine

    NASA Technical Reports Server (NTRS)

    McGinnis, Patrick J.

    2000-01-01

    Electronic Medical Records (EMR) have been emerging over the past decade. Today, they are replacing the paper chart in clinics throughout the nation. Approximately three years ago, the NASA-JSC Flight Medicine Clinic initiated an assessment of the EMRs available on the market. This assessment included comparing these products with the particular scope of practice at JSC. In 1998, the Logician EMR from Medicalogic was selected for the JSC Flight Medicine Clinic. This presentation reviews the process of selection and implementation of the EMR into the unique practice of aerospace medicine at JSC.

  19. Virtual medical record implementation for enhancing clinical decision support.

    PubMed

    Gomoi, Valentin-Sergiu; Dragu, Daniel; Stoicu-Tivadar, Vasile

    2012-01-01

    Development of clinical decision support systems (CDS) is a process which highly depends on the local databases, this resulting in low interoperability. To increase the interoperability of CDS a standard representation of clinical information is needed. The paper suggests a CDS architecture which integrates several HL7 standards and the new vMR (virtual Medical Record). The clinical information for the CDS systems (the vMR) is represented with Topic Maps technology. Beside the implementation of the vMR, the architecture integrates: a Data Manager, an interface, a decision making system (based on Egadss), a retrieving data module. Conclusions are issued.

  20. Integration of radiographic images with an electronic medical record.

    PubMed Central

    Overhage, J. M.; Aisen, A.; Barnes, M.; Tucker, M.; McDonald, C. J.

    2001-01-01

    Radiographic images are important and expensive diagnostic tests. However, the provider caring for the patient often does not review the images directly due to time constraints. Institutions can use picture archiving and communications systems to make images more available to the provider, but this may not be the best solution. We integrated radiographic image review into the Regenstrief Medical Record System in order to address this problem. To achieve adequate performance, we store JPEG compressed images directly in the RMRS. Currently, physicians review about 5% of all radiographic studies using the RMRS image review function. PMID:11825241

  1. Patient clustering with uncoded text in electronic medical records.

    PubMed

    Henao, Ricardo; Murray, Jared; Ginsburg, Geoffrey; Carin, Lawrence; Lucas, Joseph E

    2013-01-01

    We propose a mixture model for text data designed to capture underlying structure in the history of present illness section of electronic medical records data. Additionally, we propose a method to induce bias that leads to more homogeneous sets of diagnoses for patients in each cluster. We apply our model to a collection of electronic records from an emergency department and compare our results to three other relevant models in order to assess performance. Results using standard metrics demonstrate that patient clusters from our model are more homogeneous when compared to others, and qualitative analyses suggest that our approach leads to interpretable patient sub-populations when applied to real data. Finally, we demonstrate an example of our patient clustering model to identify adverse drug events.

  2. Applying XDS for sharing CDA-based medical records

    NASA Astrophysics Data System (ADS)

    Kim, Joong Il; Jang, Bong Mun; Han, Dong Hoon; Yang, Keon Ho; Kang, Won-Suk; Jung, Haijo; Kim, Hee-Joung

    2006-03-01

    Many countries have set long-term objectives for establishing an Electronic Healthcare Records system(EHRs). Various IT Strategies note that integration of EHR systems has a high priority. Because the EHR systems are based on different information models and different technology platforms, one of the key integration problems in the realization of the EHRs for the continuity of patient care, is the inability to share patient records between various institutions. Integrating the Healthcare Enterprise (IHE) committee has defined the detailed implementations of existing standards such as DICOM, HL7, in a publicly available document called the IHE technical framework (IHE-TF). Cross-enterprise document sharing (XDS), one of IHE technical frameworks, is describing how to apply the standards into the information systems for the sharing of medical documents among hospitals. This study aims to design Clinical Document Architecture (CDA) schema based on HL7, and to apply implementation strategies of XDS using this CDA schema.

  3. Patient Clustering with Uncoded Text in Electronic Medical Records

    PubMed Central

    Henao, Ricardo; Murray, Jared; Ginsburg, Geoffrey; Carin, Lawrence; Lucas, Joseph E.

    2013-01-01

    We propose a mixture model for text data designed to capture underlying structure in the history of present illness section of electronic medical records data. Additionally, we propose a method to induce bias that leads to more homogeneous sets of diagnoses for patients in each cluster. We apply our model to a collection of electronic records from an emergency department and compare our results to three other relevant models in order to assess performance. Results using standard metrics demonstrate that patient clusters from our model are more homogeneous when compared to others, and qualitative analyses suggest that our approach leads to interpretable patient sub-populations when applied to real data. Finally, we demonstrate an example of our patient clustering model to identify adverse drug events. PMID:24551361

  4. 28 CFR 513.44 - Fees for copies of Inmate Central File and Medical Records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... Institution for Information § 513.44 Fees for copies of Inmate Central File and Medical Records. Within a... and Medical Records. 513.44 Section 513.44 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... disclosable documents maintained in the Inmate Central File and Medical Record. Fees for the copies are to...

  5. 77 FR 42555 - Proposed Information Collection (Request for and Authorization To Release Medical Records or...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-19

    ... AFFAIRS Proposed Information Collection (Request for and Authorization To Release Medical Records or... solicits comments on information needed to obtain a patient written consent to disclose medical records or... Medical Records or Health Information, VA Form 10-5345. b. Individual's Request for a Copy of their...

  6. 41 CFR 51-9.303-2 - Special requirements for medical/psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... medical/psychological records. 51-9.303-2 Section 51-9.303-2 Public Contracts and Property Management... for medical/psychological records. (a) The Executive Director may require an individual who requests access to his medical or psychological record to designate a physician of his choice to whom he...

  7. 41 CFR 51-9.303-2 - Special requirements for medical/psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... medical/psychological records. 51-9.303-2 Section 51-9.303-2 Public Contracts and Property Management... for medical/psychological records. (a) The Executive Director may require an individual who requests access to his medical or psychological record to designate a physician of his choice to whom he...

  8. 32 CFR 1801.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 6 2010-07-01 2010-07-01 false Special procedures for medical and psychological... Special procedures for medical and psychological records. (a) In general. When a request for access or amendment involves medical or psychological records and when the originator determines that such records...

  9. School Administration Handbook for Approved Schools for Medical Record Technicians. Revised April 66.

    ERIC Educational Resources Information Center

    American Association of Medical Record Librarians, Chicago, IL.

    These guidelines are for the development and operation of approved programs to prepare medical record technicians. "School Approval" discusses the cooperative roles of the American Medical Association (AMA) Council on Medical Education and the American Association of Medical Record Librarians (AAMRL) in connection with program approval, and other…

  10. Gastrointestinal problems in 15q duplication syndrome.

    PubMed

    Shaaya, Elias A; Pollack, Sarah F; Boronat, Susana; Davis-Cooper, Shelby; Zella, Garrett C; Thibert, Ronald L

    2015-03-01

    Chromosome 15q duplication syndrome (Dup15q syndrome) is a neurodevelopmental disorder involving copy number gains of the maternal chromosome 15q11.2-q13 region, characterized by intellectual disability, developmental delay, autism spectrum disorder (ASD), and epilepsy. Gastrointestinal (GI) problems in Dup15q syndrome have been reported only rarely, mostly focused on neonatal feeding difficulties. A retrospective review of the medical records of 46 patients with Dup15q syndrome was conducted to assess GI issues and their treatments in this population. GI symptoms were present in 76.7% of subjects with an isodicentric duplication and 87.5% with an interstitial duplication. There was no clear association between GI issues and ASD, with symptoms occurring in 78.9% of all subjects and 78.2% of ASD subjects. The most commonly reported symptoms were gastroesophageal reflux (56.7%) and constipation (60%), with 30% of subjects reporting both. The most common treatments were polyethylene glycol for constipation and proton pump inhibitors for reflux. Behaviors such as irritability and aggressiveness improved with treatment of GI symptoms in several subjects. The results indicate that GI symptoms are common in Dup15q syndrome and may have an atypical presentation. Diagnosis may be difficult, especially in individuals who are nonverbal or minimally verbal, so increased awareness is critical for early diagnosis and treatment.

  11. Medical record linkage in health information systems by approximate string matching and clustering

    PubMed Central

    Sauleau, Erik A; Paumier, Jean-Philippe; Buemi, Antoine

    2005-01-01

    Background Multiplication of data sources within heterogeneous healthcare information systems always results in redundant information, split among multiple databases. Our objective is to detect exact and approximate duplicates within identity records, in order to attain a better quality of information and to permit cross-linkage among stand-alone and clustered databases. Furthermore, we need to assist human decision making, by computing a value reflecting identity proximity. Methods The proposed method is in three steps. The first step is to standardise and to index elementary identity fields, using blocking variables, in order to speed up information analysis. The second is to match similar pair records, relying on a global similarity value taken from the Porter-Jaro-Winkler algorithm. And the third is to create clusters of coherent related records, using graph drawing, agglomerative clustering methods and partitioning methods. Results The batch analysis of 300,000 "supposedly" distinct identities isolates 240,000 true unique records, 24,000 duplicates (clusters composed of 2 records) and 3,000 clusters whose size is greater than or equal to 3 records. Conclusion Duplicate-free databases, used in conjunction with relevant indexes and similarity values, allow immediate (i.e.: real-time) proximity detection when inserting a new identity. PMID:16219102

  12. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    .... Medical records must stress the psychiatric components of the record, including history of findings and... record of mental status; (4) Note the onset of illness and the circumstances leading to admission;...

  13. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    .... Medical records must stress the psychiatric components of the record, including history of findings and... record of mental status; (4) Note the onset of illness and the circumstances leading to admission;...

  14. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    .... Medical records must stress the psychiatric components of the record, including history of findings and... record of mental status; (4) Note the onset of illness and the circumstances leading to admission;...

  15. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    .... Medical records must stress the psychiatric components of the record, including history of findings and... record of mental status; (4) Note the onset of illness and the circumstances leading to admission;...

  16. Relevance of the electronic computer to hospital medical records.

    PubMed

    Mitchell, J H

    1969-10-18

    During the past 30 years an "information explosion" has completely changed patterns of illness. Unit files of individual patients have become so large that they are increasingly difficult both to store physically and to assimilate mentally. We have reached a communications barriers which poses a major threat to the efficient practice of clinical medicine.At the same time a new kind of machine, the electronic digital computer, which was invented only 26 years ago, has already come to dominate large areas of military, scientific, commercial, and industrial activity. Its supremacy rests on its ability to perform any data procedure automatically and incredibly quickly.Computers are being employed in clinical medicine in hospitals for various purposes. They can act as arithmetic calculators, they can process and analyse output from recording devices, and they can make possible the automation of various machine systems.However, in the field of case records their role is much less well defined, for here the organization of data as a preliminary to computer input is the real stumbling-block. Data banks of retrospective selected clinical information have been in operation in some centres for a number of years. Attempts are now being made to design computerized "total information systems" to replace conventional paper records, and the possibility of automated diagnosis is being seriously discussed.In my view, however, the medical profession is in danger of being dazzled by optimistic claims about the usefulness of computers in case record processing. The solution to the present problems of record storage and handling is very simple, and does not involve computerization.

  17. A clinical trial of a knowledge-based medical record.

    PubMed

    Safran, C; Rind, D M; Davis, R B; Sands, D Z; Caraballo, E; Rippel, K; Wang, Q; Rury, C; Makadon, H J; Cotton, D J

    1995-01-01

    To meet the needs of primary care physicians caring for patients with HIV infection, we developed a knowledge-based medical record to allow the on-line patient record to play an active role in the care process. These programs integrate the on-line patient record, rule-based decision support, and full-text information retrieval into a clinical workstation for the practicing clinician. To determine whether use of a knowledge-based medical record was associated with more rapid and complete adherence to practice guidelines and improved quality of care, we performed a controlled clinical trial among physicians and nurse practitioners caring for 349 patients infected with the human immuno-deficiency virus (HIV); 191 patients were treated by 65 physicians and nurse practitioners assigned to the intervention group, and 158 patients were treated by 61 physicians and nurse practitioners assigned to the control group. During the 18-month study period, the computer generated 303 alerts in the intervention group and 388 in the control group. The median response time of clinicians to these alerts was 11 days in the intervention group and 52 days in the control group (PJJ0.0001, log-rank test). During the study, the computer generated 432 primary care reminders for the intervention group and 360 reminders for the control group. The median response time of clinicians to these alerts was 114 days in the intervention group and more than 500 days in the control group (PJJ0.0001, log-rank test). Of the 191 patients in the intervention group, 67 (35%) had one or more hospitalizations, compared with 70 (44%) of the 158 patients in the control group (PJ=J0.04, Wilcoxon test stratified for initial CD4 count). There was no difference in survival between the intervention and control groups (P = 0.18, log-rank test). We conclude that our clinical workstation significantly changed physicians' behavior in terms of their response to alerts regarding primary care interventions and that these

  18. Change Management – Recommendations for Successful Electronic Medical Records Implementation

    PubMed Central

    Shoolin, J.S.

    2010-01-01

    Summary Change is difficult and managing change even more so. With the advent of Electronic Medical Records (EMRs) and the difficulty of its acceptance, understanding physician’s attitudes and the psychology of change management is imperative. While many authors describe change management theories, one comes nearest to describing this particularly difficult transition. In 1969, Elizabeth Kübler-Ross wrote her seminal treatise, On Death and Dying, detailing the psychological changes terminally ill patients undergo. Her grieving model is a template to examine the impact of change. By following a physician through the EMR maze, understanding the difficulties he/she perceives and developing a plan other change agents are able to use, the paper gives practical recommendations to EMR change management. PMID:23616842

  19. Role prediction using Electronic Medical Record system audits.

    PubMed

    Zhang, Wen; Gunter, Carl A; Liebovitz, David; Tian, Jian; Malin, Bradley

    2011-01-01

    Electronic Medical Records (EMRs) provide convenient access to patient data for parties who should have it, but, unless managed properly, may also provide it to those who should not. Distinguishing the two is a core security challenge for EMRs. Strategies proposed to address these problems include Role Based Access Control (RBAC), which assigns collections of privileges called roles to users, and Experience Based Access Management (EBAM), which analyzes audit logs to determine access rights. In this paper, we integrate RBAC and EBAM through an algorithm, called Roll-Up, to manage roles effectively. In doing so, we introduce the concept of "role prediction" to identify roles from audit data. We apply the algorithm to three months of logs from Northwestern Memorial Hospital's Cerner system with approximately 8000 users and 140 roles. We demonstrate that existing roles can be predicted with 50% accuracy and intelligent grouping of roles through Roll-Up can facilitate 65% accuracy.

  20. Forward secure digital signature for electronic medical records.

    PubMed

    Yu, Yao-Chang; Huang, To-Yeh; Hou, Ting-Wei

    2012-04-01

    The Technology Safeguard in Health Insurance Portability and Accountability Act (HIPAA) Title II has addressed a way to maintain the integrity and non-repudiation of Electronic Medical Record (EMR). One of the important cryptographic technologies is mentioned in the ACT is digital signature; however, the ordinary digital signature (e.g. DSA, RSA, GQ...) has an inherent weakness: if the key (certificate) is updated, than all signatures, even the ones generated before the update, are no longer trustworthy. Unfortunately, the current most frequently used digital signature schemes are categorized into the ordinary digital signature scheme; therefore, the objective of this paper is to analyze the shortcoming of using ordinary digital signatures in EMR and to propose a method to use forward secure digital signature to sign EMR to ensure that the past EMR signatures remain trustworthy while the key (certificate) is updated.

  1. Factors Affecting Accuracy of Data Abstracted from Medical Records

    PubMed Central

    Zozus, Meredith N.; Pieper, Carl; Johnson, Constance M.; Johnson, Todd R.; Franklin, Amy; Smith, Jack; Zhang, Jiajie

    2015-01-01

    Objective Medical record abstraction (MRA) is often cited as a significant source of error in research data, yet MRA methodology has rarely been the subject of investigation. Lack of a common framework has hindered application of the extant literature in practice, and, until now, there were no evidence-based guidelines for ensuring data quality in MRA. We aimed to identify the factors affecting the accuracy of data abstracted from medical records and to generate a framework for data quality assurance and control in MRA. Methods Candidate factors were identified from published reports of MRA. Content validity of the top candidate factors was assessed via a four-round two-group Delphi process with expert abstractors with experience in clinical research, registries, and quality improvement. The resulting coded factors were categorized into a control theory-based framework of MRA. Coverage of the framework was evaluated using the recent published literature. Results Analysis of the identified articles yielded 292 unique factors that affect the accuracy of abstracted data. Delphi processes overall refuted three of the top factors identified from the literature based on importance and five based on reliability (six total factors refuted). Four new factors were identified by the Delphi. The generated framework demonstrated comprehensive coverage. Significant underreporting of MRA methodology in recent studies was discovered. Conclusion The framework generated from this research provides a guide for planning data quality assurance and control for studies using MRA. The large number and variability of factors indicate that while prospective quality assurance likely increases the accuracy of abstracted data, monitoring the accuracy during the abstraction process is also required. Recent studies reporting research results based on MRA rarely reported data quality assurance or control measures, and even less frequently reported data quality metrics with research results. Given

  2. Intranet-based multi-purpose medical records in orthopaedics.

    PubMed

    Dugas, M; Bosch, R; Paulus, R; Lenz, T

    1999-01-01

    Quality assurance in orthopaedics--as in any medical speciality--relies on precise medical records. Data quality is crucial for statistical evaluation; missing values cannot be avoided but must be minimized. The quality assurance system must be accessible from many locations within the clinic; given the complex and heterogeneous computing infrastructure this is a technological challenge. Intranet technology--the application of internet-tools in local networks--can help to solve the technical problems. A generic Intranet-based quality assurance system in orthopaedics was designed, implemented and evaluated. The basic concept is an intranet data entry form which is generated semi-automatically from the data definition. This form is adapted according to the individual needs of the doctors (intelligent data entry). By flexible data transformation the same data set is used for clinical reports as well as scientific evaluations. The first use was for ultrasound examinations of neonatal hips. A report form consisting of 56 items was designed. Within the first 9-month period 1303 cases have been documented.

  3. Roles of Medical Record and Statistic Staff on Research at the Tawanchai Center.

    PubMed

    Pattaranit, Rumpan; Chantachum, Vasana; Lekboonyasin, Orathai; Pradubwong, Suteera

    2015-08-01

    The medical record and statistic staffs play a crucial role behind the achievements of treatment and research of physicians, nurses and other health care professionals. The medical record and statistic staff are in charge of keeping patient medical records; creating databases; presenting information; sorting patient's information; providing patient medical records and related information for various medical teams and researchers; Besides, the medical record and statistic staff have collaboration with the Center of Cleft Lip-Palate, Khon Kaen University in association with the Tawanchai Project. The Tawanchai Center is an organization, involving multidisciplinary team which aims to continuing provide care for patients with cleft lip and palate and craniofacial deformities who need a long term of treatment since newborns until the age of 19 years. With support and encouragement from the Tawanchai team, the medical record and statistic staff have involved in research under the Tawanchai Centre since then and produced a number of publications locally and internationally.

  4. Factors in medical student beliefs about electronic health record use.

    PubMed

    Harle, Christopher A; Gruber, Laura A; Dewar, Marvin A

    2014-01-01

    Healthcare providers' ongoing investment in electronic health records (EHRs) necessitates an understanding of physicians' expectations about using EHRs. Such understanding may aid educators and administrators when utilizing scarce resources during EHR training and implementation activities. This study aimed to link individual medical student characteristics to their perceptions of EHRs' ease of use and usefulness. This study employed a cross-sectional survey of 126 third-year medical students at a large southeastern university. Using a questionnaire designed for this study and containing previously validated items, the study team measured and related students' expectations about EHR ease of use and usefulness to their computer self-efficacy, openness to change, personality traits, and demographic characteristics. On a seven-point scale, men reported, on average, ease-of-use scores that were 0.71 higher than women's (p < .001). Also, increased computer self-efficacy related to higher expectations of EHR ease of use (p < .01) and usefulness (p < .05). Openness-to-change scores were also associated with higher expectations of EHR ease of use (p < .01) and usefulness (p < .001). Finally, a more conscientious personality was positively associated with EHR ease of use (p < .01). Our findings suggest that medical educators and administrators may consider targeting EHR management strategies on the basis of individual differences. Enhanced training and support interventions may be helpful to women or to clinicians with lower computer self-efficacy, lower openness to change, or less conscientious personalities. Also, current and future physicians who rate higher in terms of self-efficacy, openness to change, or conscientiousness may be useful as champions of EHR use among their peers.

  5. [An electronic medical record information system of DICOM-RT module-based in radiation therapy].

    PubMed

    Xia, Deguo; Zhou, Linghong; Lei, Li

    2012-06-01

    Electronic medical records (EMR) is the clinical diagnosis, guiding intervention and digital medical service record of outpatient, hospital patients (or care object) in medical institution. And it is the complete, detailed clinical information resource which has produced and recorded in all previous medical treatments. Radiotherapy electronic medical records contain texts, images and graphics, therefore the information is more complicated. This paper proposes an EMR information system based on DICOM-RT standard, through the use of seven objects of DICOM-RT to achieve the information exchange and sharing between different systems, equipments, convenient radiotherapy treatment data management, improve the efficiency of radiation treatment.

  6. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... medical use. 35.2063 Section 35.2063 Energy NUCLEAR REGULATORY COMMISSION MEDICAL USE OF BYPRODUCT MATERIAL Records § 35.2063 Records of dosages of unsealed byproduct material for medical use. (a) A... must contain— (1) The radiopharmaceutical; (2) The patient's or human research subject's name,...

  7. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... medical use. 35.2063 Section 35.2063 Energy NUCLEAR REGULATORY COMMISSION MEDICAL USE OF BYPRODUCT MATERIAL Records § 35.2063 Records of dosages of unsealed byproduct material for medical use. (a) A... must contain— (1) The radiopharmaceutical; (2) The patient's or human research subject's name,...

  8. Embracing the Sparse, Noisy, and Interrelated Aspects of Patient Demographics for use in Clinical Medical Record Linkage.

    PubMed

    Ash, Stephen M; Ip-Lin, King

    2015-01-01

    Duplicate patient records in health information systems have received increased attention in recent time due to regulatory incentives to integrate the healthcare enterprise. Historically, most patient record matching systems have been limited to simple applications of the Fellegi-Sunter theory of record linkage with edit distance based string similarity measurements. String similarity approaches ignore the rich semantic information present by reducing it to a simple syntactic comparison of characters. This work describes an updated approach to building clinical medical record linkage systems, which embraces the unavoidable problems present in real-world patient matching. Using a ground truth dataset of a real patient population, we demonstrate that systems built in this fashion improve recall by 76% with little reduction in precision. This result empirically demonstrates the size of the gap between sophisticated systems and naïve approaches. Additionally, it accentuates the difficulty in estimating the false negative error in this setting as previous research has reported much higher levels of recall, due, in part, to measuring from biased samples. PMID:26306279

  9. Embracing the Sparse, Noisy, and Interrelated Aspects of Patient Demographics for use in Clinical Medical Record Linkage

    PubMed Central

    Ash, Stephen M.; Ip-Lin, King

    2015-01-01

    Duplicate patient records in health information systems have received increased attention in recent time due to regulatory incentives to integrate the healthcare enterprise. Historically, most patient record matching systems have been limited to simple applications of the Fellegi-Sunter theory of record linkage with edit distance based string similarity measurements. String similarity approaches ignore the rich semantic information present by reducing it to a simple syntactic comparison of characters. This work describes an updated approach to building clinical medical record linkage systems, which embraces the unavoidable problems present in real-world patient matching. Using a ground truth dataset of a real patient population, we demonstrate that systems built in this fashion improve recall by 76% with little reduction in precision. This result empirically demonstrates the size of the gap between sophisticated systems and naïve approaches. Additionally, it accentuates the difficulty in estimating the false negative error in this setting as previous research has reported much higher levels of recall, due, in part, to measuring from biased samples. PMID:26306279

  10. Paperless medical records: moving from plan to reality.

    PubMed

    Tobey, Mary Ellen

    2004-01-01

    In 2002, North Shore Magnetic Imaging Center (NSMIC) decided that a major restructuring of the patient process was necessary to alleviate staff frustration and increase the level of patient care. An aggressive, 16-month timeline was established for the center to develop and implement a paperless environment. The project began by focusing on the center's existing radiology information system (RIS). Research showed that no "canned" system would perform the necessary tasks. The center's vendor, with whom senior management had developed a longstanding and trusting relationship, assured the center that, with the proper programming, the existing RIS could support the new paperless environment. Additional technology components were addressed. The first phase enabled staff to obtain physician orders and outside reports from the fax server. Once the patient medical record was fully electronic, these external documents were no longer printed. The transfer of billing information to the radiologist's billing office was achieved through a Health-Level 7 (HL7) interface between NSMIC's RIS and the information systems utilized by the billing office. Technologists were impacted when wireless personal computer (PC) tablets were implemented. Measuring 8.5" x 11" x 0.5", these tablets enable technologists to gather and record patient information while moving freely throughout the center. Forming the Reinvention Team--an internal team of NSMIC staff that would deal with the project's impact on staff, workflow, and patient care--was done in very deliberate fashion. During the recruitment phase of the project, each prospective team member was required to take 2 specific personality profile tests. The team was comprised of a combination of different personality profiles. A radiologist was later added to the team. Throughout the implementation of new processes at NSMIC, numerous breakdowns were encountered. The breakdowns could be classified into 2 categories: technical andpatient

  11. 29 CFR 1910.1020 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... employment questionnaires or histories (including job description and occupational exposures), (B) The...'s medical program and its records, (B) First aid records (not including medical histories) of one... with 29 CFR 1910.1200(g). (C) Biological monitoring results designated as exposure records by...

  12. 29 CFR 1910.1020 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... employment questionnaires or histories (including job description and occupational exposures), (B) The...'s medical program and its records, (B) First aid records (not including medical histories) of one... with 29 CFR 1910.1200(g). (C) Biological monitoring results designated as exposure records by...

  13. Patients Reading Their Medical Records: Differences in Experiences and Attitudes between Regular and Inexperienced Readers

    ERIC Educational Resources Information Center

    Huvila, Isto; Daniels, Mats; Cajander, Åsa; Åhlfeldt, Rose-Mharie

    2016-01-01

    Introduction: We report results of a study of how ordering and reading of printouts of medical records by regular and inexperienced readers relate to how the records are used, to the health information practices of patients, and to their expectations of the usefulness of new e-Health services and online access to medical records. Method: The study…

  14. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    .../psychological records. 1701.13 Section 1701.13 National Defense Other Regulations Relating to National Defense... procedures for medical/psychiatric/psychological records. Current and former ODNI employees, including... access to their medical, psychiatric or psychological testing records by writing to: Information...

  15. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    .../psychological records. 1701.13 Section 1701.13 National Defense Other Regulations Relating to National Defense... procedures for medical/psychiatric/psychological records. Current and former ODNI employees, including... access to their medical, psychiatric or psychological testing records by writing to: Information...

  16. Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center.

    PubMed

    Rizer, Milisa K; Kaufman, Beth; Sieck, Cynthia J; Hefner, Jennifer L; McAlearney, Ann Scheck

    2015-01-01

    Electronic medical record (EMR) implementation efforts face many challenges, including individual and organizational barriers and concerns about loss of productivity during the process. These issues may be particularly complex in large and diverse settings with multiple specialties providing inpatient and outpatient care. This case report provides an example of a successful EMR implementation that emphasizes the importance of flexibility and adaptability on the part of the implementation team. It also presents the top 10 lessons learned from this EMR implementation in a large midwestern academic medical center. Included are five overarching lessons related to leadership, initial approach, training, support, and optimization as well as five lessons related to the EMR system itself that are particularly important elements of a successful implementation. PMID:26396558

  17. Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center.

    PubMed

    Rizer, Milisa K; Kaufman, Beth; Sieck, Cynthia J; Hefner, Jennifer L; McAlearney, Ann Scheck

    2015-01-01

    Electronic medical record (EMR) implementation efforts face many challenges, including individual and organizational barriers and concerns about loss of productivity during the process. These issues may be particularly complex in large and diverse settings with multiple specialties providing inpatient and outpatient care. This case report provides an example of a successful EMR implementation that emphasizes the importance of flexibility and adaptability on the part of the implementation team. It also presents the top 10 lessons learned from this EMR implementation in a large midwestern academic medical center. Included are five overarching lessons related to leadership, initial approach, training, support, and optimization as well as five lessons related to the EMR system itself that are particularly important elements of a successful implementation.

  18. Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center

    PubMed Central

    Rizer, Milisa K.; Kaufman, Beth; Sieck, Cynthia J.; Hefner, Jennifer L.; McAlearney, Ann Scheck

    2015-01-01

    Electronic medical record (EMR) implementation efforts face many challenges, including individual and organizational barriers and concerns about loss of productivity during the process. These issues may be particularly complex in large and diverse settings with multiple specialties providing inpatient and outpatient care. This case report provides an example of a successful EMR implementation that emphasizes the importance of flexibility and adaptability on the part of the implementation team. It also presents the top 10 lessons learned from this EMR implementation in a large midwestern academic medical center. Included are five overarching lessons related to leadership, initial approach, training, support, and optimization as well as five lessons related to the EMR system itself that are particularly important elements of a successful implementation. PMID:26396558

  19. [A Research on the origin and development of standardization of Chinese medical case records].

    PubMed

    Zhang, Lei

    2014-11-01

    The origin of Chinese medical case history is rather early. Chunyu Yi's medical cases (zhen ji) of the Western Han Dynasty were the earliest actual extant medical case with the practical contents. In the Ming Dynasty, Han Mao put forward firstly the principles of "six aspects must be recorded" for writing the pulse record, as the beginning of the standardization of medical case record. Later, Wu Kun, Yu Yan, Li Yanzhen, He Lianchen et al. supplemented, adjusted and changed the format of medical case record. After 1949, the format of medical case record was revised several times to form the national standard. In fact, the clinical medical case record is different from the case history. The modern medical case record could not reflect fully the thinking process of traditional Chinese medicine (TCM) and the essence of the treatment based on syndrome differentiation. Exploring the origin and development of the standardization of medical case record will benefit for the improvement of modern format of medical case record. PMID:25620355

  20. IMASIS computer-based medical record project: dealing with the human factor.

    PubMed

    Martín-Baranera, M; Planas, I; Palau, J; Sanz, F

    1995-01-01

    level, problems to be solved in utilization of the system, errors detected in the systems' database, and the personal interest in participating in the IMASIS project. The questionnaire was also intended to be a tool to monitor IMASIS evolution. Our study showed that medical staff had a lack of information about the current HIS, leading to a poor utilization of some system options. Another major characteristic, related to the above, was the feeling that the project would negatively affect the organization of work at the hospitals. A computer-based medical record was feared to degrade physician-patient relationship, introduce supplementary administrative burden in clinicians day-to-day work, unnecessarily slow history taking, and imply too-rigid patterns of work. The most frequent problems in using the current system could be classified into two groups: problems related to lack of agility and consistency in user interface design, and those derived from lack of a common patient identification number. Duplication of medical records was the most frequent error detected by physicians. Analysis of physicians' attitudes towards IMASIS revealed a lack of confidence globally. This was probably the consequence of two current features: a lack of complete information about IMASIS possibilities and problems faced when using the system. To deal with such factors, three types of measures have been planned. First, an effort is to be done to ensure that every physician is able to adequately use the current system and understands long-term benefits of the project. This task will be better accomplished by personal interaction between clinicians and a physician from the Informatics Department than through formal teaching of IMASIS. Secondly, a protocol for evaluating the HIS is being developed and will be systematically applied to detect both database errors and systemUs design pitfalls. Finally, the IMASIS project has to find a convenient point for starting, to offer short-term re PMID

  1. IMASIS computer-based medical record project: dealing with the human factor.

    PubMed

    Martín-Baranera, M; Planas, I; Palau, J; Sanz, F

    1995-01-01

    level, problems to be solved in utilization of the system, errors detected in the systems' database, and the personal interest in participating in the IMASIS project. The questionnaire was also intended to be a tool to monitor IMASIS evolution. Our study showed that medical staff had a lack of information about the current HIS, leading to a poor utilization of some system options. Another major characteristic, related to the above, was the feeling that the project would negatively affect the organization of work at the hospitals. A computer-based medical record was feared to degrade physician-patient relationship, introduce supplementary administrative burden in clinicians day-to-day work, unnecessarily slow history taking, and imply too-rigid patterns of work. The most frequent problems in using the current system could be classified into two groups: problems related to lack of agility and consistency in user interface design, and those derived from lack of a common patient identification number. Duplication of medical records was the most frequent error detected by physicians. Analysis of physicians' attitudes towards IMASIS revealed a lack of confidence globally. This was probably the consequence of two current features: a lack of complete information about IMASIS possibilities and problems faced when using the system. To deal with such factors, three types of measures have been planned. First, an effort is to be done to ensure that every physician is able to adequately use the current system and understands long-term benefits of the project. This task will be better accomplished by personal interaction between clinicians and a physician from the Informatics Department than through formal teaching of IMASIS. Secondly, a protocol for evaluating the HIS is being developed and will be systematically applied to detect both database errors and systemUs design pitfalls. Finally, the IMASIS project has to find a convenient point for starting, to offer short-term re

  2. Osteoporosis guideline implementation in family medicine using electronic medical records

    PubMed Central

    Pritchard, Janet; Karampatos, Sarah; Ioannidis, George; Adachi, Jonathan; Thabane, Lehana; Nash, Lynn; Mehan, Upe; Kozak, Joseph; Feldman, Sid; Hirsch, Steve; Jovaisas, Algis V.; Cheung, Angela; Lohfeld, Lynne; Papaioannou, Alexandra

    2016-01-01

    Abstract Objective To identify family physicians’ learning needs related to osteoporosis care; determine family physicians’ preferred modes of learning; and identify barriers to using electronic medical records (EMRs) to implement osteoporosis guidelines in practice. Design Web-based survey. Setting Ontario. Participants Family physicians. Main outcome measures Quantitative and qualitative data about learning needs related to osteoporosis diagnosis and management; preferred mode of learning about guidelines; and barriers to using EMRs to implement guidelines. Results Of the 12 332 family physicians invited to participate in the survey, 8.5% and 7.0% provided partial or fully completed surveys, respectively. More than 80% of respondents agreed that the priority areas for education were as follows: selecting laboratory tests for secondary osteoporosis and interpreting the test results; interpreting bone mineral density results; determining appropriate circumstances for ordering anterior-posterior lumbar spine x-ray scans; and understanding duration, types, and adverse effects of pharmacotherapy. Qualitative analysis revealed that managing moderate-risk patients was a learning need. Continuing medical education was the preferred mode of learning. Approximately 80% of respondents agreed that the scarcity of EMR tools to aid in guideline implementation was a barrier to using guidelines, and 50% of respondents agreed that if EMR-embedded tools were available, time would limit their ability to use them. Conclusion This survey identified key diagnostic- and treatment-related topics in osteoporosis care that should be the focus of future continuing professional development for family physicians. Developers of EMR tools, physicians, and researchers aiming to implement guidelines to improve osteoporosis care should consider the potential barriers indicated in this study.

  3. Key success factors behind electronic medical record adoption in Thailand.

    PubMed

    Narattharaksa, Kanida; Speece, Mark; Newton, Charles; Bulyalert, Damrongsak

    2016-09-19

    Purpose The purpose of this paper is to investigate the elements that health care personnel in Thailand believe are necessary for successful adoption of electronic medical record (EMR) systems. Design/methodology/approach Initial qualitative in-depth interviews with physicians to adapt key elements from the literature to the Thai context. The 12 elements identified included things related to managing the implementation and to IT expertise. The nationwide survey was supported by the Ministry of Public Health and returned 1,069 usable questionnaires (response rate 42 percent) from a range of medical personnel. Findings The key elements clearly separated into a managerial dimension and an IT dimension. All were considered fairly important, but managerial expertise was more critical. In particular, there should be clear EMR project goals and scope, adequate budget allocation, clinical staff must be involved in implementation, and the IT should facilitate good electronic communication. Research limitations/implications Thailand is representative of middle-income developing countries, but there is no guarantee findings can be generalized. National policies differ, as do economic structures of health care industries. The focus is on management at the organizational level, but future research must also examine macro-level issues, as well as gain more depth into thinking of individual health care personnel. Practical implications Technical issues of EMR implementation are certainly important. However, it is clear actual adoption and use of the system also depends very heavily on managerial issues. Originality/value Most research on EMR implementation has been in developed countries, and has often focussed more on technical issues rather than examining managerial issues closely. Health IT is also critical in developing economies, and management of health IT implementation must be well understood. PMID:27681029

  4. Key success factors behind electronic medical record adoption in Thailand.

    PubMed

    Narattharaksa, Kanida; Speece, Mark; Newton, Charles; Bulyalert, Damrongsak

    2016-09-19

    Purpose The purpose of this paper is to investigate the elements that health care personnel in Thailand believe are necessary for successful adoption of electronic medical record (EMR) systems. Design/methodology/approach Initial qualitative in-depth interviews with physicians to adapt key elements from the literature to the Thai context. The 12 elements identified included things related to managing the implementation and to IT expertise. The nationwide survey was supported by the Ministry of Public Health and returned 1,069 usable questionnaires (response rate 42 percent) from a range of medical personnel. Findings The key elements clearly separated into a managerial dimension and an IT dimension. All were considered fairly important, but managerial expertise was more critical. In particular, there should be clear EMR project goals and scope, adequate budget allocation, clinical staff must be involved in implementation, and the IT should facilitate good electronic communication. Research limitations/implications Thailand is representative of middle-income developing countries, but there is no guarantee findings can be generalized. National policies differ, as do economic structures of health care industries. The focus is on management at the organizational level, but future research must also examine macro-level issues, as well as gain more depth into thinking of individual health care personnel. Practical implications Technical issues of EMR implementation are certainly important. However, it is clear actual adoption and use of the system also depends very heavily on managerial issues. Originality/value Most research on EMR implementation has been in developed countries, and has often focussed more on technical issues rather than examining managerial issues closely. Health IT is also critical in developing economies, and management of health IT implementation must be well understood.

  5. Development and Use of Mark Sense Record Cards for Recording Medical Data on Pilots Subjected to Acceleration Stress

    NASA Technical Reports Server (NTRS)

    Smedal, Harald A.; Havill, C. Dewey

    1962-01-01

    A TIME-HONORED system of recording medical histories and the data obtained on physical and laboratory examination has been that of writing the information on record sheets that go into a folder for each patient. In order to have information which would be more readily retrieved, 'a program was initiated in 1952 by the U. S. Naval School of Aviation Medicine in connection with their "Care of the Flyer" study to place this information on machine record cards. In 1958, a machine record card method was developed for recording medical data in connection with the astronaut selection program. Machine record cards were also developed by the Aero Medical Laboratory, Wright-Patterson AFB, Ohio, and the Aviation Medical Acceleration Laboratory, Naval Air Development Center, Johnsville, Pennsylvania, for use in connection with a variety of tests including acceleration stress.1 Therefore, a variety of systems resulted in which data of a medical nature could easily be recalled. During the NASA, Ames Research Center centrifuge studies/'S the pilot subjects were interviewed after each centrifuge run, or series of runs, and subjective information was recorded in a log book by the usual history taking methods referred to above. After the methods Were reviewed, it' was recognized that a card system would be very useful in recording data from our pilots after they had been exposed to acceleration stress. Since the acceleration stress cards already developed did not meet our requirements, it was decided a different card was needed.

  6. Characterization of Statin Dose-response within Electronic Medical Records

    PubMed Central

    Wei, Wei-Qi; Feng, Qiping; Jiang, Lan; Waitara, Magarya S.; Iwuchukwu, Otito F.; Roden, Dan M.; Jiang, Min; Xu, Hua; Krauss, Ronald M.; Rotter, Jerome I.; Nickerson, Deborah A.; Davis, Robert L.; Berg, Richard L.; Peissig, Peggy L.; McCarty, Catherine A.; Wilke, Russell A.; Denny, Joshua C.

    2013-01-01

    Efforts to define the genetic architecture underlying variable statin response have met with limited success possibly because previous studies were limited to effect based on one-single-dose. We leveraged electronic medical records (EMRs) to extract potency (ED50) and efficacy (Emax) of statin dose-response curves and tested them for association with 144 pre-selected variants. Two large biobanks were used to construct dose-response curves for 2,026 (simvastatin) and 2,252 subjects (atorvastatin). Atorvastatin was more efficacious, more potent, and demonstrated less inter-individual variability than simvastatin. A pharmacodynamic variant emerging from randomized trials (PRDM16) was associated with Emax for both. For atorvastatin, Emax was 51.7 mg/dl in homozygous for the minor allele versus 75.0 mg/dl for those homozygous for the major allele. We also identified several loci associated with ED50. The extraction of rigorously defined traits from EMRs for pharmacogenetic studies represents a promising approach to further understand of genetic factors contributing to drug response. PMID:24096969

  7. Development of Mobile Platform Integrated with Existing Electronic Medical Records

    PubMed Central

    Kim, YoungAh; Kang, Simon; Kim, Kyungduk; Kim, Jun

    2014-01-01

    Objectives This paper describes a mobile Electronic Medical Record (EMR) platform designed to manage and utilize the existing EMR and mobile application with optimized resources. Methods We structured the mEMR to reuse services of retrieval and storage in mobile app environments that have already proven to have no problem working with EMRs. A new mobile architecture-based mobile solution was developed in four steps: the construction of a server and its architecture; screen layout and storyboard making; screen user interface design and development; and a pilot test and step-by-step deployment. This mobile architecture consists of two parts, the server-side area and the client-side area. In the server-side area, it performs the roles of service management for EMR and documents and for information exchange. Furthermore, it performs menu allocation depending on user permission and automatic clinical document architecture document conversion. Results Currently, Severance Hospital operates an iOS-compatible mobile solution based on this mobile architecture and provides stable service without additional resources, dealing with dynamic changes of EMR templates. Conclusions The proposed mobile solution should go hand in hand with the existing EMR system, and it can be a cost-effective solution if a quality EMR system is operated steadily with this solution. Thus, we expect this example to be shared with hospitals that currently plan to deploy mobile solutions. PMID:25152837

  8. Improving the medical records department processes by lean management

    PubMed Central

    Ajami, Sima; Ketabi, Saeedeh; Sadeghian, Akram; Saghaeinnejad-Isfahani, Sakine

    2015-01-01

    Background: Lean management is a process improvement technique to identify waste actions and processes to eliminate them. The benefits of Lean for healthcare organizations are that first, the quality of the outcomes in terms of mistakes and errors improves. The second is that the amount of time taken through the whole process significantly improves. Aims: The purpose of this paper is to improve the Medical Records Department (MRD) processes at Ayatolah-Kashani Hospital in Isfahan, Iran by utilizing Lean management. Materials and Methods: This research was applied and an interventional study. The data have been collected by brainstorming, observation, interview, and workflow review. The study population included MRD staff and other expert staff within the hospital who were stakeholders and users of the MRD. Statistical Analysis Used: The MRD were initially taught the concepts of Lean management and then formed into the MRD Lean team. The team then identified and reviewed the current processes subsequently; they identified wastes and values, and proposed solutions. Results: The findings showed that the MRD units (Archive, Coding, Statistics, and Admission) had 17 current processes, 28 wastes, and 11 values were identified. In addition, they offered 27 comments for eliminating the wastes. Conclusion: The MRD is the critical department for the hospital information system and, therefore, the continuous improvement of its services and processes, through scientific methods such as Lean management, are essential. Originality/Value: The study represents one of the few attempts trying to eliminate wastes in the MRD. PMID:26097862

  9. A critical pathway for electronic medical record selection.

    PubMed

    Holbrook, A; Keshavjee, K; Langton, K; Troyan, S; Millar, S; Olantunji, S; Pray, M; Tytus, R; Ford, P T

    2001-01-01

    Electronic medical records (EMRs) are increasingly becoming a necessary tool in health care. Given their potential to influence every aspect of health care, there has been surprisingly little rigorous research applied to this important piece of emerging health technology. An initial phase of the COMPETE study, which is examining the impact of EMRs on efficiency, quality of care and privacy concerns, involved a rigorous "critical pathway" approach to EMR selection for the study. A multidisciplinary team with clinical, technical and research expertise led an 8-stage evaluation process with direct input from user physicians at each stage. An iterative sequence of review of EMR specifications and features, live product demonstrations, site visits, and negotiations with vendors led to a progressive narrowing of the field of eligible EMR systems. Final scoring was based on 3 main themes of clinical usability, data quality and support/vendor issues. We believe that a rigorous, multidisciplinary process such as this is required to maximize success of any EMR implementation project.

  10. Consumers' Perceptions of Patient-Accessible Electronic Medical Records

    PubMed Central

    Vaughon, Wendy L; Czaja, Sara J; Levy, Joslyn; Rockoff, Maxine L

    2013-01-01

    Background Electronic health information (eHealth) tools for patients, including patient-accessible electronic medical records (patient portals), are proliferating in health care delivery systems nationally. However, there has been very limited study of the perceived utility and functionality of portals, as well as limited assessment of these systems by vulnerable (low education level, racial/ethnic minority) consumers. Objective The objective of the study was to identify vulnerable consumers’ response to patient portals, their perceived utility and value, as well as their reactions to specific portal functions. Methods This qualitative study used 4 focus groups with 28 low education level, English-speaking consumers in June and July 2010, in New York City. Results Participants included 10 males and 18 females, ranging in age from 21-63 years; 19 non-Hispanic black, 7 Hispanic, 1 non-Hispanic White and 1 Other. None of the participants had higher than a high school level education, and 13 had less than a high school education. All participants had experience with computers and 26 used the Internet. Major themes were enhanced consumer engagement/patient empowerment, extending the doctor’s visit/enhancing communication with health care providers, literacy and health literacy factors, improved prevention and health maintenance, and privacy and security concerns. Consumers were also asked to comment on a number of key portal features. Consumers were most positive about features that increased convenience, such as making appointments and refilling prescriptions. Consumers raised concerns about a number of potential barriers to usage, such as complex language, complex visual layouts, and poor usability features. Conclusions Most consumers were enthusiastic about patient portals and perceived that they had great utility and value. Study findings suggest that for patient portals to be effective for all consumers, portals must be designed to be easy to read, visually

  11. Anonymization of DICOM electronic medical records for radiation therapy.

    PubMed

    Newhauser, Wayne; Jones, Timothy; Swerdloff, Stuart; Newhauser, Warren; Cilia, Mark; Carver, Robert; Halloran, Andy; Zhang, Rui

    2014-10-01

    Electronic medical records (EMR) and treatment plans are used in research on patient outcomes and radiation effects. In many situations researchers must remove protected health information (PHI) from EMRs. The literature contains several studies describing the anonymization of generic Digital Imaging and Communication in Medicine (DICOM) files and DICOM image sets but no publications were found that discuss the anonymization of DICOM radiation therapy plans, a key component of an EMR in a cancer clinic. In addition to this we were unable to find a commercial software tool that met the minimum requirements for anonymization and preservation of data integrity for radiation therapy research. The purpose of this study was to develop a prototype software code to meet the requirements for the anonymization of radiation therapy treatment plans and to develop a way to validate that code and demonstrate that it properly anonymized treatment plans and preserved data integrity. We extended an open-source code to process all relevant PHI and to allow for the automatic anonymization of multiple EMRs. The prototype code successfully anonymized multiple treatment plans in less than 1min/patient. We also tested commercial optical character recognition (OCR) algorithms for the detection of burned-in text on the images, but they were unable to reliably recognize text. In addition, we developed and tested an image filtering algorithm that allowed us to isolate and redact alpha-numeric text from a test radiograph. Validation tests verified that PHI was anonymized and data integrity, such as the relationship between DICOM unique identifiers (UID) was preserved. PMID:25147130

  12. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... requirements for psychiatric hospitals. 482.61 Section 482.61 Public Health CENTERS FOR MEDICARE & MEDICAID... PARTICIPATION FOR HOSPITALS Requirements for Specialty Hospitals § 482.61 Condition of participation: Special medical record requirements for psychiatric hospitals. The medical records maintained by a...

  13. 77 FR 55221 - Agency Information Collection Activities: Report of Medical Examination and Vaccination Record...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-07

    ..., at 77 FR 36285, allowing for a 60-day public comment period. USCIS received one submission from one... Medical Examination and Vaccination Record, Form I-693; Revision of a Currently Approved Collection ACTION...: Report of Medical Examination and Vaccination Record. (3) Agency form number, if any, and the...

  14. Improving the Quality of Nursing Home Care and Medical-Record Accuracy with Direct Observational Technologies

    ERIC Educational Resources Information Center

    Schnelle, John F.; Osterweil, Dan; Simmons, Sandra F.

    2005-01-01

    Nursing home medical-record documentation of daily-care occurrence may be inaccurate, and information is not documented about important quality-of-life domains. The inadequacy of medical record data creates a barrier to improving care quality, because it supports an illusion of care consistent with regulations, which reduces the motivation and…

  15. Congruence of Self-Reported Medications with Pharmacy Prescription Records in Low-Income Older Adults

    ERIC Educational Resources Information Center

    Caskie, Grace I. L.; Willis, Sherry L.

    2004-01-01

    Purpose: This study examined the congruence of self-reported medications with computerized pharmacy records. Design and Methods: Pharmacy records and self-reported medications were obtained for 294 members of a state pharmaceutical assistance program who also participated in ACTIVE, a clinical trial on cognitive training in nondemented elderly…

  16. Urban Alabama Physicians and the Electronic Medical Record: A Qualitative Study

    ERIC Educational Resources Information Center

    Tiggle, Michele

    2012-01-01

    The electronic medical record (EMR) is an information technology tool supporting the examination, treatment, and care of a patient. The EMR allows physicians to view a patient's record showing current medications, a history of visits from health care providers with notes from those visits, a problem list, a functional status assessment, a…

  17. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... of majority. (a) The Air Force must obey state laws protecting medical records of drug or alcohol abuse treatment, abortion, and birth control. If you manage medical records, learn the local laws and... sought or consented to treatment between the ages of 15 and 17 in a program where regulation or...

  18. 20 CFR 30.113 - What are the requirements for written medical documentation, contemporaneous records, and other...

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... documentation, contemporaneous records, and other records or documents? 30.113 Section 30.113 Employees... written medical documentation, contemporaneous records, and other records or documents? (a) All written medical documentation, contemporaneous records, and other records or documents submitted by an employee...

  19. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE...

  20. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients...

  1. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients...

  2. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients...

  3. Linking human anatomy to knowledge bases: a visual front end for electronic medical records.

    PubMed

    Dickson, Stewart; Pouchard, Line; Ward, Richard; Atkins, Gary; Cole, Martin; Lorensen, Bill; Ade, Alexander

    2005-01-01

    A new concept of a visual electronic medical record is presented based on developments ongoing in the Defense Advanced Research Projects Agency Virtual Soldier Project. This new concept is based on the holographic medical electronic representation (Holomer) and on data formats being developed to support this. The Holomer is being developed in two different visualization environments, one of which is suitable for prototyping the visual electronic medical record. The advantages of a visual approach as a front end for electronic medical records are discussed and specific implementations are presented. PMID:15718802

  4. Standards for medical identifiers, codes, and messages needed to create an efficient computer-stored medical record. American Medical Informatics Association.

    PubMed Central

    1994-01-01

    A major obstacle to establishing a computer-stored medical record is the lack of "standards" that would permit government, care providers, insurance companies, and medical computer system developers to share patient data easily. In this position paper, the Board of Directors of the American Medical Informatics Association recommends specific approaches to standardization in the areas of patient, provider, and site of care identifiers; computerized health care message exchange; medical record content and structure, and medical codes and terminologies. The key concept developed in this position paper is that developers and users of computer-stored medical records must embrace existing and tested approaches, despite their imperfections, to progress quickly. This approach to standardization is being coordinated with the American National Standards Institute's Health Informatics Standards Planning Panel. The development of standards is a long-term process involving continued refinement. The proposed standards are an important step toward the goal of better and more efficient health care. PMID:7719784

  5. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  6. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  7. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  8. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  9. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  10. DRUG-DRUG INTERACTION PROFILES OF MEDICATION REGIMENS EXTRACTED FROM A DE-IDENTIFIED ELECTRONIC MEDICAL RECORDS SYSTEM

    PubMed Central

    Butkiewicz, Mariusz; Restrepo, Nicole A.; Haines, Jonathan L.; Crawford, Dana C.

    2016-01-01

    With age, the number of prescribed medications increases and subsequently raises the risk for adverse drug-drug interactions. These adverse effects lower quality of life and increase health care costs. Quantifying the potential burden of adverse effects before prescribing medications can be a valuable contribution to health care. This study evaluated medication lists extracted from a subset of the Vanderbilt de-identified electronic medical record system. Reported drugs were cross-referenced with the Kyoto Encyclopedia of Genes and Genomes DRUG database to identify known drug-drug interactions. On average, a medication regimen contained 6.58 medications and 2.68 drug-drug interactions. Here, we quantify the burden of potential adverse events from drug-drug interactions through drug-drug interaction profiles and include a number of alternative medications as provided by the Anatomical Therapeutic Chemical Classification System. PMID:27570646

  11. DRUG-DRUG INTERACTION PROFILES OF MEDICATION REGIMENS EXTRACTED FROM A DE-IDENTIFIED ELECTRONIC MEDICAL RECORDS SYSTEM.

    PubMed

    Butkiewicz, Mariusz; Restrepo, Nicole A; Haines, Jonathan L; Crawford, Dana C

    2016-01-01

    With age, the number of prescribed medications increases and subsequently raises the risk for adverse drug-drug interactions. These adverse effects lower quality of life and increase health care costs. Quantifying the potential burden of adverse effects before prescribing medications can be a valuable contribution to health care. This study evaluated medication lists extracted from a subset of the Vanderbilt de-identified electronic medical record system. Reported drugs were cross-referenced with the Kyoto Encyclopedia of Genes and Genomes DRUG database to identify known drug-drug interactions. On average, a medication regimen contained 6.58 medications and 2.68 drug-drug interactions. Here, we quantify the burden of potential adverse events from drug-drug interactions through drug-drug interaction profiles and include a number of alternative medications as provided by the Anatomical Therapeutic Chemical Classification System. PMID:27570646

  12. The sensitivity of medical diagnostic decision-support knowledge bases in delineating appropriate terms to document in the medical record.

    PubMed Central

    Feldman, M. J.; Barnett, G. O.; Morgan, M. M.

    1991-01-01

    A pertinent, legible and complete medical record facilitates good patient care. The recording of the symptoms, signs and lab findings which are relevant to a patient's condition contributes importantly to the medical record. The consideration and documentation of other disease states known to be related to the patient's primary illness provide further enhancement. We propose that developing sets of disease-specific core elements which a physician may want to document in the medical record can have many benefits. We hypothesize that for a given disease, terms with high importance (TI) and frequency (TF) in the DX-plain, QMR and Iliad knowledge bases (KBs) are terms which are used commonly in the medical record, and may be, in fact, terms which physicians would find useful to document. A study was undertaken to validate ten such sets of disease-specific core elements. For each of ten prevalent diseases, high TI and TF terms from the three KBs mentioned were pooled to derive the set of core elements. For each disease, all patient records (range 385 to 16,972) from a computerized ambulatory medical record database were searched to document the actual use by physicians of each of these core elements. A significant percentage (range 50 to 86%) of each set of core elements was confirmed as being used by the physicians. In addition, all medical concepts from a selection of full text records were identified, and an average of 65% of the concepts were found to be core elements.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:1807600

  13. Using the Electronic Medical Record to Assess Contraception Usage among Women Taking Category D or X Medications

    PubMed Central

    Mody, Sheila K; Farala, John Paul; Wu, Jennifer; Felix, Robert; Chambers, Christina

    2016-01-01

    Background The aim of this study is to investigate contraceptive usage among women prescribed or currently taking a category D or X medication using the electronic medical record. Methods This is a retrospective study assessing contraceptive usage among women prescribed category D or X medications. We obtained access to the electronic medical records of women seen in an academic Family Medicine Department between April 2011 and April 2012 who were prescribed a category D or X medication. Information was abstracted regarding the specific category D or X medication, demographics, sexual activity, sexual partner gender, and contraceptive usage. Results There were a total of 610 women included in this study. Among the 610 women, 72 (11.8%) of women had documentation that they were not asked about their sexual activity. Sexual activity with men was documented in 407 of the 610 women (66.7%). Of these 407 women, 132 (32.4%) had no contraceptive method documented. Among the women using contraception, the most common method used was oral contraception. Conclusion According to data obtained from the electronic medical record, women who are taking a category D or X medication are not always asked about sexual activity. Contraception usage among women taking category D or X medications and who were sexually active with men was similar to the general population. Contraception usage should be better in this population given the risk of an unintended pregnancy includes fetal exposure to a potential teratogen. The electronic medical record creates an opportunity for an intervention to increase contraception utilization in this population. PMID:26306028

  14. Technology and Health Care: Efficiency, Frustration, and Disconnect in the Transition to Electronic Medical Records

    PubMed Central

    Magsamen-Conrad, Kate; Checton, Maria

    2014-01-01

    This study investigates one medical facility's transition to electronic medical records (becoming “paperless”). We utilized face-to-face interviews to investigate the transition process with one implementer (the vice president of the medical facility) and three stakeholders from one of the four offices (an assistant office manager, a nurse, and a medical technician). We discuss the dominant themes of efficiency, frustration, and disconnect as well as conclusions and implications. PMID:25729754

  15. Medical records. Enhancing privacy, preserving the common good.

    PubMed

    Etzioni, A

    1999-01-01

    Personal medical information is now bought and sold on the open market. Companies use it to make hiring and firing decisions and to identify customers for new products. The justification for providing such access to medical information is that doing so benefits the public by securing public safety, controlling costs, and supporting medical research. And individuals have supposedly consented to it. But we can achieve the common goods while better protecting privacy by making institutional changes in the way information is maintained and protected. PMID:10321335

  16. Physician Interaction with Electronic Medical Records: A Qualitative Study

    ERIC Educational Resources Information Center

    Noteboom, Cherie Bakker

    2010-01-01

    The integration of EHR (Electronic Health Records) in IT infrastructures supporting organizations enable improved access to and recording of patient data, enhanced ability to make better and more-timely decisions, and improved quality and reduced errors. Despite these benefits, there are mixed results as to the use of EHR. The literature suggests…

  17. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... the last provision of service. (b) A licensee shall retain the record of each survey required by § 35.80(a)(4) for 3 years. The record must include the date of the survey, the results of the survey, the instrument used to make the survey, and the name of the individual who performed the survey....

  18. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... the last provision of service. (b) A licensee shall retain the record of each survey required by § 35.80(a)(4) for 3 years. The record must include the date of the survey, the results of the survey, the instrument used to make the survey, and the name of the individual who performed the survey....

  19. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... the last provision of service. (b) A licensee shall retain the record of each survey required by § 35.80(a)(4) for 3 years. The record must include the date of the survey, the results of the survey, the instrument used to make the survey, and the name of the individual who performed the survey....

  20. 5 CFR 293.505 - Establishment and protection of Employee Medical Folder.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... the employee leaves the employing agency and occupational medical records for that employee exist...) Neither the original occupational medical record nor duplicates are to be retained in the OPF. Prior to.... An EMF must be under the control of a specifically designated medical, health, safety, or...

  1. A computerised out-patient medical records programme based on the Summary Time-Oriented Record (STOR) System.

    PubMed

    Cheong, P Y; Goh, L G; Ong, R; Wong, P K

    1992-12-01

    Advances in microcomputer hardware and software technology have made computerised outpatient medical records practical. We have developed a programme based on the Summary Time-Oriented Record (STOR) system which complements existing paper-based record keeping. The elements of the Problem Oriented Medical Record (POMR) System are displayed in two windows within one screen, namely, the SOAP (Subjective information, Objective information, Assessments and Plans) elements in the Reason For Encounter (RFE) window and the problem list with outcomes in the Problem List (PL) window. Context sensitive child windows display details of plans of management in the RFE window and clinical notes in the PL window. The benefits of such innovations to clinical decision making and practice based research and its medico-legal implications are discussed.

  2. A Software System to Collect Expert Relevance Ratings of Medical Record Items for Specific Clinical Tasks

    PubMed Central

    Krishnaraj, Arun; Alkasab, Tarik K

    2014-01-01

    Development of task-specific electronic medical record (EMR) searches and user interfaces has the potential to improve the efficiency and safety of health care while curbing rising costs. The development of such tools must be data-driven and guided by a strong understanding of practitioner information requirements with respect to specific clinical tasks or scenarios. To acquire this important data, this paper describes a model by which expert practitioners are leveraged to identify which components of the medical record are most relevant to a specific clinical task. We also describe the computer system that was created to efficiently implement this model of data gathering. The system extracts medical record data from the EMR of patients matching a given clinical scenario, de-identifies the data, breaks the data up into separate medical record items (eg, radiology reports, operative notes, laboratory results, etc), presents each individual medical record item to experts under the hypothetical of the given clinical scenario, and records the experts’ ratings regarding the relevance of each medical record item to that specific clinical scenario or task. After an iterative process of data collection, these expert relevance ratings can then be pooled and used to design point-of-care EMR searches and user interfaces tailored to the task-specific needs of practitioners. PMID:25600925

  3. Duplication in DNA Sequences

    NASA Astrophysics Data System (ADS)

    Ito, Masami; Kari, Lila; Kincaid, Zachary; Seki, Shinnosuke

    The duplication and repeat-deletion operations are the basis of a formal language theoretic model of errors that can occur during DNA replication. During DNA replication, subsequences of a strand of DNA may be copied several times (resulting in duplications) or skipped (resulting in repeat-deletions). As formal language operations, iterated duplication and repeat-deletion of words and languages have been well studied in the literature. However, little is known about single-step duplications and repeat-deletions. In this paper, we investigate several properties of these operations, including closure properties of language families in the Chomsky hierarchy and equations involving these operations. We also make progress toward a characterization of regular languages that are generated by duplicating a regular language.

  4. TECHNIQUES OF TAPE PREPARATION AND DUPLICATION, WITH SUGGESTIONS FOR A LANGUAGE LABORATORY.

    ERIC Educational Resources Information Center

    Kansas State Dept. of Public Instruction, Topeka.

    PART ONE OF THIS BULLETIN PROVIDES HELP IN THE TWO CRITICAL AREAS OF MASTER TAPE PREPARATION AND DUPLICATION. SUPPLEMENTED BY NUMEROUS PHOTOGRAPHS AND DIAGRAMS OF EQUIPMENT AND DUPLICATION TECHNIQUES, THE BULLETIN DESCRIBES MASTER PROGRAM DUPLICATION USING LANGUAGE LABORATORY EQUIPMENT, A PROFESSIONAL MASS DUPLICATOR, A TAPE RECORDER, A RECORD…

  5. Does the HIPAA Privacy Rule Allow Parents the Right to See Their Children's Medical Records?

    MedlinePlus

    ... Does the HIPAA Privacy Rule allow parents the right to see their children’s medical records? Answer: Yes, ... your contact information below. Email Office for Civil Rights Headquarters U.S. Department of Health & Human Services 200 ...

  6. The mixed management of patients' medical records: responsibility sharing between the patient and the physician.

    PubMed

    Quantin, Catherine; Fassa, Maniane; Benzenine, Eric; Jaquet-Chiffelle, David-Olivier; Coatrieux, Gouenou; Allaert, François-André

    2010-01-01

    Through this article, we propose a mixed management of patients' medical records, so as to share responsibilities between the patient and the Medical Practitioner by making Patients responsible for the validation of their administrative information, and MPs responsible for the validation of their Patients' medical information. Our proposal can be considered a solution to the main problem faced by patients, health practitioners and the authorities, namely the gathering and updating of administrative and medical data belonging to the patient in order to accurately reconstitute a patient's medical history. This method is based on two processes. The aim of the first process is to provide a patient's administrative data, in order to know where and when the patient received care (name of the health structure or health practitioner, type of care: out patient or inpatient). The aim of the second process is to provide a patient's medical information and to validate it under the accountability of the Medical Practitioner with the help of the patient if needed. During these two processes, the patient's privacy will be ensured through cryptographic hash functions like the Secure Hash Algorithm, which allows pseudonymisation of a patient's identity. The proposed Medical Record Search Engines will be able to retrieve and to provide upon a request formulated by the Medical Practitioner all the available information concerning a patient who has received care in different health structures without divulging the patient's identity. Our method can lead to improved efficiency of personal medical record management under the mixed responsibilities of the patient and the MP.

  7. Electronic Medical Record and Quality Ratings of Long Term Care Facilities Long-Term Care Facility Characteristics and Reasons and Barriers for Adoption of Electronic Medical Record

    ERIC Educational Resources Information Center

    Daniels, Cheryl Andrea

    2013-01-01

    With the growing elderly population, compounded by the retirement of the babyboomers, the need for long-term care (LTC) facilities is expected to grow. An area of great concern for those that are seeking a home for their family member is the quality of care provided by the nursing home to the residents. Electronic medical records (EMR) are often…

  8. Development of Markup Language for Medical Record Charting: A Charting Language.

    PubMed

    Jung, Won-Mo; Chae, Younbyoung; Jang, Bo-Hyoung

    2015-01-01

    Nowadays a lot of trials for collecting electronic medical records (EMRs) exist. However, structuring data format for EMR is an especially labour-intensive task for practitioners. Here we propose a new mark-up language for medical record charting (called Charting Language), which borrows useful properties from programming languages. Thus, with Charting Language, the text data described in dynamic situation can be easily used to extract information.

  9. Documentation of Medical Records in Hospitals of Mazandaran University of Medical Sciences in 2014: a Quantitative Study

    PubMed Central

    Saravi, Benyamin Mohseni; Asgari, Zolaykha; Siamian, Hasan; Farahabadi, Ebrahim Bagherian; Gorji, Alimorad Heidari; Motamed, Nima; Fallahkharyeki, Mohammad; Mohammadi, Ramin

    2016-01-01

    Introduction: Documentation of patient care in medical record formats is always emphasized. These documents are used as a means to go on treating the patients, staff in their own defense, assessment, care, any legal proceedings and medical science education. Therefore, in this study, each of the data elements available in patients’ records are important and filling them indicates the importance put by the documenting teams, so it has been dealt with the documentation the patient records in the hospitals of Mazandaran province. Method: This cross-sectional study aimed to review medical records in 16 hospitals of Mazandaran University of Medical Sciences (MazUMS). In order to collection data, a check list was prepared based on the data elements including four forms of the admission, summary, patients’ medical history and progress note. The data recording was defined as “Yes” with the value of 1, lack of recording was defined as “No” with the value of 2, and “Not applied” with the value of 0 for the cases in which the mentioned variable medical records are not applied. Results: The overall evaluation of the documentation was considered as 95-100% equal to “good”, 75-94% equal to “average” and below -75% equal to “poor”. Using the stratified random sample volume formula, 381 cases were reviewed. The data were analyzed by the SPSS version 19 and descriptive statistics. Results: The results showed that %62 of registration and all the four forms were in the “poor” category. There was no big difference in average registration among the hospitals. Among the educational groups Gynecology and Infectious were equal and had the highest average of documentation of %68. In the data categories, the highest documentation average belonged to the verification, %91. Conclusion: According to the overall assessment in which the rate of documentation was in the category “week”, we should make much more efforts to reach better conditions. Even if a data

  10. Survey of electronic veterinary medical record adoption and use by independent small animal veterinary medical practices in Massachusetts

    PubMed Central

    Krone, Lauren M.; Brown, Catherine M.; Lindenmayer, Joann M.

    2016-01-01

    Objective To estimate the proportion of independent small animal veterinary medical practices in Massachusetts that use electronic veterinary medical records (EVMRs), determine the purposes for which EVMRs are used, and identify perceived barriers to their use. Design Survey. Sample 100 veterinarians. Procedures 213 of 517 independent small animal veterinary practices operating in Massachusetts were randomly chosen for study recruitment. One veterinarian at each practice was invited by telephone to answer a hardcopy survey regarding practice demographics, medical records type (electronic, paper, or both), purposes of EVMR use, and perceived barriers to adoption. Surveys were mailed to the first 100 veterinarians who agreed to participate. Practices were categorized by record type and size (large [≥ 5 veterinarians], medium [3 to 4 veterinarians], or small [1 to 2 veterinarians]). Results 84 surveys were returned; overall response was 84 of 213 (39.4%). The EVMRs were used alone or together with paper records in 66 of 82 (80.5%) practices. Large and medium-sized practices were significantly more likely to use EVMRs combined with paper records than were small practices. The EVMRs were most commonly used for ensuring billing, automating reminders, providing cost estimates, scheduling, recording medical and surgical information, and tracking patient health. Least common uses were identifying emerging infectious diseases, research, and insurance. Eleven veterinarians in paper record–only practices indicated reluctance to change, anticipated technological problems, time constraints, and cost were barriers to EVMR use. Conclusions and Clinical Relevance Results indicated EVMRs were underutilized as a tool for tracking and improving population health and identifying emerging infectious diseases. Efforts to facilitate adoption of EVMRs for these purposes should be strengthened by the veterinary medical, human health, and public health professions. PMID:25029312

  11. ClinicalCodes: an online clinical codes repository to improve the validity and reproducibility of research using electronic medical records.

    PubMed

    Springate, David A; Kontopantelis, Evangelos; Ashcroft, Darren M; Olier, Ivan; Parisi, Rosa; Chamapiwa, Edmore; Reeves, David

    2014-01-01

    Lists of clinical codes are the foundation for research undertaken using electronic medical records (EMRs). If clinical code lists are not available, reviewers are unable to determine the validity of research, full study replication is impossible, researchers are unable to make effective comparisons between studies, and the construction of new code lists is subject to much duplication of effort. Despite this, the publication of clinical codes is rarely if ever a requirement for obtaining grants, validating protocols, or publishing research. In a representative sample of 450 EMR primary research articles indexed on PubMed, we found that only 19 (5.1%) were accompanied by a full set of published clinical codes and 32 (8.6%) stated that code lists were available on request. To help address these problems, we have built an online repository where researchers using EMRs can upload and download lists of clinical codes. The repository will enable clinical researchers to better validate EMR studies, build on previous code lists and compare disease definitions across studies. It will also assist health informaticians in replicating database studies, tracking changes in disease definitions or clinical coding practice through time and sharing clinical code information across platforms and data sources as research objects. PMID:24941260

  12. Achieving order entry by physicians in a computerized medical record.

    PubMed

    Larson, R L; Blake, J P

    1988-06-01

    When Community Memorial Hospital selected a computerized Medical Information System (MIS), it was recognized that physician use and acceptance was paramount to success. To achieve this, active participation from the medical-dental staff via an advisory committee, system education and emphasis on physician benefits was sought. Advance preparation included selection of light pen technology, field trips by selected physicians to other hospitals with the same system, and strategic placement and availability of terminals. During implementation, training was scheduled at the convenience of the physician. This training continues to be offered immediately to new physicians as they join the staff. System upgrades and added functions prompt scheduling of demonstrations for interested physicians. Many developmental ideas come from physicians using MIS indicating their interest in maintaining the system. New approaches that will make order entry easier for physicians so that everyone can benefit from their cooperation and participation are continually being looked for.

  13. 29 CFR 1904.9 - Recording criteria for cases involving medical removal under OSHA standards.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... surveillance requirements of an OSHA standard, you must record the case on the OSHA 300 Log. (b) Implementation—(1) How do I classify medical removal cases on the OSHA 300 Log? You must enter each medical removal case on the OSHA 300 Log as either a case involving days away from work or a case involving...

  14. Organizational Learning and Large-Scale Change: Adoption of Electronic Medical Records

    ERIC Educational Resources Information Center

    Chavis, Virginia D.

    2010-01-01

    Despite implementation of electronic medical record (EMR) systems in the United States and other countries, there is no organizational development model that addresses medical professionals' attitudes toward technology adoption in a learning organization. The purpose of this study was to assess whether a model would change those attitudes toward…

  15. Medical records for animals used in research, teaching, and testing: public statement from the American College of Laboratory Animal Medicine.

    PubMed

    Field, Karl; Bailey, Michele; Foresman, Larry L; Harris, Robert L; Motzel, Sherri L; Rockar, Richard A; Ruble, Gaye; Suckow, Mark A

    2007-01-01

    Medical records are considered to be a key element of a program of adequate veterinary care for animals used in research, teaching, and testing. However, prior to the release of the public statement on medical records by the American College of Laboratory Animal Medicine (ACLAM), the guidance that was available on the form and content of medical records used for the research setting was not consistent and, in some cases, was considered to be too rigid. To address this concern, ACLAM convened an ad hoc Medical Records Committee and charged the Committee with the task of developing a medical record guideline that was based on both professional judgment and performance standards. The Committee provided ACLAM with a guidance document titled Public Statements: Medical Records for Animals Used in Research, Teaching, and Testing, which was approved by ACLAM in late 2004. The ACLAM public statement on medical records provides guidance on the definition and content of medical records, and clearly identifies the Attending Veterinarian as the individual who is charged with authority and responsibility for oversight of the institution's medical records program. The document offers latitude to institutions in the precise form and process used for medical records but identifies typical information to be included in such records. As a result, the ACLAM public statement on medical records provides practical yet flexible guidelines to assure that documentation of animal health is performed in research, teaching, and testing situations.

  16. Recording wounds: Polaroid's new medically-designed cameras.

    PubMed

    Clarke, G

    2000-11-01

    Wound management is an important and increasingly complex area of nursing practice. Community nurses, in particular, spend a considerable amount of time assessing, evaluating and managing chronic, non-healing wounds. The rapid rise in the number of wound care products, combined with the emphasis on clinical governance and risk management, and increases in litigation have meant that accurate documentation and record keeping have become an essential part of care (UKCC, 1992, 1998). A standardized approach to assessment, classification, measurement and evaluation should be adopted to maximize optimal patient outcomes. There are a number of techniques for measuring wounds, ranging from manual measurement using tracing to computer-based imaging. Photography is a simple and quick form of documentation, which provides an accurate and objective record of the wound. This article highlights the benefits of using the new Polaroid Macro 5 SLR camera in wound documentation. PMID:12066058

  17. Surgeons' perspective of a newly initiated electronic medical record.

    PubMed

    Frazee, Richard; Harmon, Laura; Papaconstantinou, Harry T

    2016-01-01

    The American Recovery and Reinvestment Act mandates "meaningful use" of an electronic health record (EHR) to receive current financial incentives and to avoid future financial penalties. Surgeons' ongoing adoption of an EHR nationally will be influenced by the early experiences of institutions that have made the transition from paper to electronic records. We conducted a survey to query surgeons at our institution regarding their perception of the EHR 3 months after institutional implementation. A total of 59 surveys were obtained from 24 senior staff and 35 residents. Results showed that surgeons believed the EHR was more effective as a billing tool than as a form of clinical documentation and believed the billing was more complete and accurate with the EHR. Surgeons also expressed concern that the EHR would negatively impact patient satisfaction, but in spite of this, they indicated that their personal quality of life was not negatively impacted.

  18. 42 CFR 482.24 - Condition of participation: Medical record services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... State laws, court orders, or subpoenas. (c) Standard: Content of record. The medical record must contain... such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital... with nationally recognized and evidence-based guidelines; (iii) Ensures that the periodic and...

  19. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... professional designated by the parent or guardian in all cases. If disclosure of the record would constitute an... component of the Department. Therefore, components may follow the paragraph (b) procedure for notification... purposes. The special procedure set forth in paragraph (c) of this section relating to medical records...

  20. 28 CFR 513.44 - Fees for copies of Inmate Central File and Medical Records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Fees for copies of Inmate Central File and Medical Records. 513.44 Section 513.44 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE GENERAL MANAGEMENT AND ADMINISTRATION ACCESS TO RECORDS Release of Information Inmate Requests...

  1. The urban underserved: Attitudes toward gaining full access to electronic medical records

    PubMed Central

    Dhanireddy, Shireesha; Walker, Jan; Reisch, Lisa; Oster, Natalia; Delbanco, Thomas; Elmore, Joann

    2012-01-01

    Background As the use of electronic medical records (EMRs) spreads, health care organizations are increasingly offering patients online access to their medical records. Studies evaluating patient attitudes toward viewing elements of their records through secure, electronic patient portals have generally not included medically underserved patients or those with HIV/AIDS. The goal of this study was to gain insight into such patients’ attitudes toward online access to their medical records, including their doctors’ visit notes. Methods Qualitative study of four focus groups with adult patients in general adult medicine and HIV clinics at a large county hospital. Transcripts were analyzed for themes using an immersion/crystallization approach. Results Patients’ baseline understanding of the health record was limited. Perceived benefits of online access were improved patient understanding of health and disease, convenience, empowerment, and a stronger relationship with their provider. Concerns included threats to privacy, worries about being unable to understand their record, fear that the computer would replace direct provider contact, and hesitancy about potential demands on a provider’s time. Patients also recommended providing online visit reminders, links to credible health information, and assistance for paying bills. Conclusion Despite their initial lack of knowledge of the health record, focus group participants were overwhelmingly positive about the prospect of online access to medical records. However, they worried about potential loss of privacy and interference with the patient-provider relationship. As EMRs increasingly offer patients open access to their medical records, vulnerable patient groups will likely join others in desiring and adopting such change, but may need targeted support during times of transition. PMID:22738155

  2. Marco (Medical Record Communications) - System Concept, Design and Evaluation

    PubMed Central

    Moffatt, P. H.; Heisler, B. D.; Mela, W. D.; Alpert, J. J.; Goldstein, H.M.

    1978-01-01

    MARCO, an interfacility communication system, has been designed to promote safe relevant health care delivery to the inner city pediatric patient receiving care in a network consisting of Boston City Hospital and its affiliated Neighborhood Health Centers. This application of computer technology to communication of medical information compiled on an individual patient in multiple locations has implications for private group practice as well as other urban networks similar to our own. This paper provides the MARCO system concept, the system design and evaluation of its success after two years of operation.

  3. Occupational Safety and Health Administration--Access to employee exposure and medical records. Final rule.

    PubMed

    1980-05-23

    This final occupational safety and health standard, promulgated today as a revised 29 CFR 1910.20, provides for employee, designated representative, and OSHA access to employer-maintained exposure and medical records relevant to employees exposed to toxic substances and harmful physical agents. Access is also assured to employer analyses using exposure and medical records. The final standard requires long term preservation of these records, contains provisions concerning informing employees of their rights under the standard, and includes provisions protective of trade secret information.

  4. Performance analysis of distributed and centralized models for electronic medical record exchanges.

    PubMed

    Huang, Ean-Wen; Lee, Chiung-San; Jiang, Wey-Wen; Chiou, Shwu-Fen; Liu, Fei-Ying; Liou, Der-Ming

    2007-01-01

    Electronic medical record exchanges can save time and reduce cost by eliminating redundant data and typing errors. The major steps of record exchange consist of querying information from database, encoding data into messages, and sending and decoding messages. Three medical-record-exchange models were proposed in the past, including the distributed, centralized, and indexed models. In this paper, the queuing theory is applied to evaluate the performance of the three models. We estimate the service time for each queue of the CPU, database and network, and predict the response time, probable bottlenecks and system capacities of each model.

  5. Patients, privacy and trust: patients' willingness to allow researchers to access their medical records.

    PubMed

    Damschroder, Laura J; Pritts, Joy L; Neblo, Michael A; Kalarickal, Rosemarie J; Creswell, John W; Hayward, Rodney A

    2007-01-01

    The federal Privacy Rule, implemented in the United States in 2003, as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), created new restrictions on the release of medical information for research. Many believe that its restrictions have fallen disproportionately on researchers prompting some to call for changes to the Rule. Here we ask what patients think about researchers' access to medical records, and what influences these opinions. A sample of 217 patients from 4 Veteran Affairs (VA) facilities deliberated in small groups at each location with the opportunity to question experts and inform themselves about privacy issues related to medical records research. After extensive deliberation, these patients were united in their inclination to share their medical records for research. Yet they were also united in their recommendations to institute procedures that would give them more control over whether and how their medical records are used for research. We integrated qualitative and quantitative results to derive a better understanding of this apparent paradox. Our findings can best be presented as answers to questions related to five dimensions of trust: Patients' trust in VA researchers was the most powerful determinant of the kind of control they want over their medical records. More specifically, those who had lower trust in VA researchers were more likely to recommend a more stringent process for obtaining individual consent. Insights on the critical role of trust suggest actions that researchers and others can take to more fully engage patients in research.

  6. Method and system for determining precursors of health abnormalities from processing medical records

    DOEpatents

    None, None

    2013-06-25

    Medical reports are converted to document vectors in computing apparatus and sampled by applying a maximum variation sampling function including a fitness function to the document vectors to reduce a number of medical records being processed and to increase the diversity of the medical records being processed. Linguistic phrases are extracted from the medical records and converted to s-grams. A Haar wavelet function is applied to the s-grams over the preselected time interval; and the coefficient results of the Haar wavelet function are examined for patterns representing the likelihood of health abnormalities. This confirms certain s-grams as precursors of the health abnormality and a parameter can be calculated in relation to the occurrence of such a health abnormality.

  7. Using an iconic language to improve access to electronic medical records in general medicine.

    PubMed

    Simon, Christian; Hassler, Sylvain; Beuscart-Zephir, Marie-Catherine; Favre, Madeleine; Venot, Alain; Duclos, Catherine; Lamy, Jean-Baptiste

    2014-01-01

    Physicians have difficulties to access and analyse information in a medical record. In a previous work on drug databanks, we have shown that with an iconic language as VCM, an icon-based presentation can help physicians to access medical information. Our objective, herein, is to study whether VCM can be used in an electronic medical record for facilitating physician access in general practice. We identify the data and the functionalities of an electronic medical record that could benefit from VCM icons representing clinical findings, patient history, etc. We also present a preliminary evaluation of this new icon-focused interface. We conclude by discussing the results like the assessment of the user's satisfaction and pointing out the importance of coding data.

  8. Giving Patients Access to Their Medical Records via the Internet

    PubMed Central

    Masys, Daniel; Baker, Dixie; Butros, Amy; Cowles, Kevin E.

    2002-01-01

    Objective: The Patient-Centered Access to Secure Systems Online (pcasso) project is designed to apply state-of-the-art-security to the communication of clinical information over the Internet. Design: The authors report the legal and regulatory issues associated with deploying the system, and results of its use by providers and patients. Human subject protection concerns raised by the Institutional Review Board focused on three areas—unauthorized access to information by persons other than the patient; the effect of startling or poorly understood information; and the effect of patient access to records on the record-keeping behavior of providers. Measurements: Objective and subjective measures of security and usability were obtained. Results: During its initial deployment phase, the project enrolled 216 physicians and 41 patients; of these, 68 physicians and 26 patients used the system one or more times. The system performed as designed, with no unauthorized information access or intrusions detected. Providers rated the usability of the system low because of the complexity of the secure login and other security features and restrictions limiting their access to those patients with whom they had a professional relationship. In contrast, patients rated the usability and functionality of the system favorably. Conclusion: High-assurance systems that serve both patients and providers will need to address differing expectations regarding security and ease of use. PMID:11861633

  9. Automatic quality of life prediction using electronic medical records.

    PubMed

    Pakhomov, Sergeui; Shah, Nilay; Hanson, Penny; Balasubramaniam, Saranya; Smith, Steven A; Smith, Steven Allan

    2008-11-06

    Health related quality of life (HRQOL) is an important variable used for prognosis and measuring outcomes in clinical studies and for quality improvement. We explore the use of a general pur-pose natural language processing system Metamap in combination with Support Vector Machines (SVM) for predicting patient responses on standardized HRQOL assessment instruments from text of physicians notes. We surveyed 669 patients in the Mayo Clinic diabetes registry using two instruments designed to assess functioning: EuroQoL5D and SF36/SD6. Clinical notes for these patients were represented as sets of medical concepts using Metamap. SVM classifiers were trained using various feature selection strategies. The best concordance between the HRQOL instruments and automatic classification was achieved along the pain dimension (positive agreement .76, negative agreement .78, kappa .54) using Metamap. We conclude that clinicians notes may be used to develop a surrogate measure of patients HRQOL status.

  10. Auditing medical records accesses via healthcare interaction networks.

    PubMed

    Chen, You; Nyemba, Steve; Malin, Bradley

    2012-01-01

    Healthcare organizations are deploying increasingly complex clinical information systems to support patient care. Traditional information security practices (e.g., role-based access control) are embedded in enterprise-level systems, but are insufficient to ensure patient privacy. This is due, in part, to the dynamic nature of healthcare, which makes it difficult to predict which care providers need access to what and when. In this paper, we show that modeling operations at a higher level of granularity (e.g., the departmental level) are stable in the context of a relational network, which may enable more effective auditing strategies. We study three months of access logs from a large academic medical center to illustrate that departmental interaction networks exhibit certain invariants, such as the number, strength, and reciprocity of relationships. We further show that the relations extracted from the network can be leveraged to assess the extent to which a patient's care satisfies expected organizational behavior.

  11. Auditing Medical Records Accesses via Healthcare Interaction Networks

    PubMed Central

    Chen, You; Nyemba, Steve; Malin, Bradley

    2012-01-01

    Healthcare organizations are deploying increasingly complex clinical information systems to support patient care. Traditional information security practices (e.g., role-based access control) are embedded in enterprise-level systems, but are insufficient to ensure patient privacy. This is due, in part, to the dynamic nature of healthcare, which makes it difficult to predict which care providers need access to what and when. In this paper, we show that modeling operations at a higher level of granularity (e.g., the departmental level) are stable in the context of a relational network, which may enable more effective auditing strategies. We study three months of access logs from a large academic medical center to illustrate that departmental interaction networks exhibit certain invariants, such as the number, strength, and reciprocity of relationships. We further show that the relations extracted from the network can be leveraged to assess the extent to which a patient’s care satisfies expected organizational behavior. PMID:23304277

  12. Stimulation, Recording Potential and Antimicrobial Medical Catheter Coatings

    PubMed Central

    Beard, Richard B.; DeLaurent, Mark; Pourrezaei, Kambiz; Adrian, Sorin

    1994-01-01

    Biocompatibility of electrodes for stimulation are difficult to maintain homeostasis. Noble metal stimulating electrodes which are normally biocompatible on keratinized tissue become very non-biocompatible when they are interfaced with nonkeratinized tissue in an area such as the oral cavity. Composite electrodes have been made biocompatible in the oral cavity even at current densities larger than 1 μA/mm2. Electrodes used in potential readings require that the anodic and cathodic polarization remain minimal. Silver-silver chloride electrodes are minimal. Silver-silver chloride electrodes are not always reversible. The range of pH, voltages and current densities when silver-silver chloride are not reversible are presented. Recently at Drexel University reliable silver coatings inside and outside of medical catheters have been fabricated to act as antimicrobial to a variety of bacteria. Noble and nonnoble metals have been combined in coatings with silver to enhance the antimicrobial action. PMID:18476262

  13. [Pressure ulcer care quality indicator: analysis of medical records and incident report].

    PubMed

    dos Santos, Cássia Teixeira; Oliveira, Magáli Costa; Pereira, Ana Gabriela da Silva; Suzuki, Lyliam Midori; Lucena, Amália de Fátima

    2013-03-01

    Cross-sectional study that aimed to compare the data reported in a system for the indication of pressure ulcer (PU) care quality, with the nursing evolution data available in the patients' medical records, and to describe the clinical profile and nursing diagnosis of those who developed PU grade 2 or higher Sample consisted of 188 patients at risk for PU in clinical and surgical units. Data were collected retrospectively from medical records and a computerized system of care indicators and statistically analyzed. Of the 188 patients, 6 (3%) were reported for pressure ulcers grade 2 or higher; however, only 19 (10%) were recorded in the nursing evolution records, thus revealing the underreporting of data. Most patients were women, older adults and patients with cerebrovascular diseases. The most frequent nursing diagnosis was risk of infection. The use of two or more research methodologies such as incident reporting data and retrospective review of patients' records makes the results trustworthy.

  14. A scheme for assuring lifelong readability in computer based medical records.

    PubMed

    Matsumura, Yasushi; Kurabayashi, Noriyuki; Iwasaki, Tetsuya; Sugaya, Shuichi; Ueda, Kanayo; Mineno, Takahiro; Takeda, Hiroshi

    2010-01-01

    Medical records must be kept over an extended period of time, meanwhile computer based medical records are renewed every 5-6 years. Readability of medical records must be assured even though the systems are renewed by different vendors. To achieve this, we proposed a method called DACS, in which a medical record is considered as an aggregation of documents. A Document generated by a system is transformed to a format read by free software such as PDF, which is transferred with the document meta-information and important data written on the XML to the Document Deliverer. It stores these data into the Document Archiver, the Document Sharing Server and the Data Warehouse (DWH). We developed the Matrix View which shows documents in chronological order, and the Tree View showing documents in class tree structure. By this method all the documents can be integrated and be viewed by a single viewer. This helps users figure out patient history and find a document being sought. In addition, documents' data can be shared among systems and analyzed by DWH. Most importantly DACS can assure the lifelong readability of medical records. PMID:20841656

  15. Semantic extraction and processing of medical records for patient-oriented visual index

    NASA Astrophysics Data System (ADS)

    Zheng, Weilin; Dong, Wenjie; Chen, Xiangjiao; Zhang, Jianguo

    2012-02-01

    To have comprehensive and completed understanding healthcare status of a patient, doctors need to search patient medical records from different healthcare information systems, such as PACS, RIS, HIS, USIS, as a reference of diagnosis and treatment decisions for the patient. However, it is time-consuming and tedious to do these procedures. In order to solve this kind of problems, we developed a patient-oriented visual index system (VIS) to use the visual technology to show health status and to retrieve the patients' examination information stored in each system with a 3D human model. In this presentation, we present a new approach about how to extract the semantic and characteristic information from the medical record systems such as RIS/USIS to create the 3D Visual Index. This approach includes following steps: (1) Building a medical characteristic semantic knowledge base; (2) Developing natural language processing (NLP) engine to perform semantic analysis and logical judgment on text-based medical records; (3) Applying the knowledge base and NLP engine on medical records to extract medical characteristics (e.g., the positive focus information), and then mapping extracted information to related organ/parts of 3D human model to create the visual index. We performed the testing procedures on 559 samples of radiological reports which include 853 focuses, and achieved 828 focuses' information. The successful rate of focus extraction is about 97.1%.

  16. Problem focused knowledge navigation: implementing the problem focused medical record and the O-HEAP note.

    PubMed

    Meyers, K C; Miller, H J; Naeymi-Rad, F

    1998-01-01

    The current organization of most Computerized Medical Records (CMR) is based on the Problem Oriented Medical Record (POMR) and the SOAP (Subjective, Objective, Assessment and Plan) note. The organizational structure of the POMR and especially the SOAP note, does not allow for optimal use of computer capabilities in the follow up note. Since follow up visits are the most common office visit by far, this is a major flaw in the CMR. The authors propose a Problem Focused Medical Record and the OHEAP (Orientation, History, Exam, Assessment and Plan) note to resolve this problem. OHEAP starts with a powerful orientation structure that brings forward the timeline, last Assessment and Plan, and Plan Results for each problem along with the patient's historical tables as the starting point of every follow up visit. The Assessment and Plan portion brings problem specific differential diagnoses and their workups along with other relevant tables such as expert systems, treatments, instructions, medical literature or pathways. This leads to Problem Focused Knowledge Navigation that brings powerful efficiencies to the CMR. By recognizing the true workflow in the longitudinal diagnosis and management of any medical problem, the efficiency of the CMR is maximized. OHEAP allows for optimal use of both personal and external data elements in the medical record. Its powerful orientation attributes minimize the time spent in analyzing the current status of the problem while its connections to problem specific databases help resolve the problem.

  17. Congruence of Self-Reported Medications With Pharmacy Prescription Records In Low-Income Older Adults

    PubMed Central

    Caskie, Grace I. L.; Willis, Sherry L.

    2013-01-01

    Purpose This study examined the congruence of self-reported medications with computerized pharmacy records. Design and Methods Pharmacy records and self-reported medications were obtained for 294 members of a state pharmaceutical assistance program who also participated in ACTIVE, a clinical trial on cognitive training in nondemented elderly persons. The average age of the sample participants was 74.5 years (range = 65–91); 87.8% were females. Results Congruence between self-report and pharmacy data was generally high. Self-reports omitted drug classes in the pharmacy records less often than the pharmacy records did not include self-reported drug classes. The percentage of individuals with perfect agreement between self-reports and pharmacy records varied from 49% for major drug classes to 81 % for specific cardiovascular and central nervous system drugs. Within a drug class, agreement tended to be higher for individuals without a prescription in that class. Poorer health was consistently related to poorer self-report of medications. Implications Self-reported medications are most likely to be congruent with pharmacy records for drugs prescribed for more serious conditions, for more specific classes of drugs, and for healthier individuals. PMID:15075414

  18. Intelligent technique for knowledge reuse of dental medical records based on case-based reasoning.

    PubMed

    Gu, Dong-Xiao; Liang, Chang-Yong; Li, Xing-Guo; Yang, Shan-Lin; Zhang, Pei

    2010-04-01

    With the rapid development of both information technology and the management of modern medical regulation, the generation of medical records tends to be increasingly intelligent. In this paper, Case-Based Reasoning is applied to the process of generating records of dental cases. Based on the analysis of the features of dental records, a case base is constructed. A mixed case retrieval method (FAIES) is proposed for the knowledge reuse of dental records by adopting Fuzzy Mathematics, which improves similarity algorithm based on Euclidian-Lagrangian Distance, and PULL & PUSH weight adjustment strategy. Finally, an intelligent system of dental cases generation (CBR-DENT) is constructed. The effectiveness of the system, the efficiency of the retrieval method, the extent of adaptation and the adaptation efficiency are tested using the constructed case base. It is demonstrated that FAIES is very effective in terms of reducing the time of writing medical records and improving the efficiency and quality. FAIES is also proven to be an effective aid for diagnoses and provides a new idea for the management of medical records and its applications.

  19. Overcoming Electronic Medical Record Challenges on the Obstetrics and Gynecology Clerkship.

    PubMed

    Buery-Joyner, Samantha D; Dalrymple, John L; Abbott, Jodi F; Craig, LaTasha B; Forstein, David A; Graziano, Scott C; Hampton, Brittany S; Hopkins, Laura; Page-Ramsey, Sarah M; Pradhan, Archana; Wolf, Abigail; Mckenzie, Margaret L

    2015-09-01

    This article, for the "To the Point" series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, supplies educators with a review of best practices regarding incorporation of the electronic medical record (EMR) into undergraduate medical education. The unique circumstances of the obstetrics and gynecology clerkship require specific attention as it pertains to medical student use of the EMR. An outline of the regulatory requirements and authoritative body recommendations provides some guidance for implementation in the undergraduate medical education setting. A review of the basic framework for development of an EMR curriculum and examples of curricular innovations published in the literature offers solutions for obstacles that may be encountered by students and medical educators.

  20. Organising European technical documentation to avoid duplication.

    PubMed

    Donawa, Maria

    2006-04-01

    The development of comprehensive accurate and well-organised technical documentation that demonstrates compliance with regulatory requirements is a resource-intensive, but critically important activity for medical device manufacturers. This article discusses guidance documents and method of organising technical documentation that may help avoid costly and time-consuming duplication.

  1. Organising European technical documentation to avoid duplication.

    PubMed

    Donawa, Maria

    2006-04-01

    The development of comprehensive accurate and well-organised technical documentation that demonstrates compliance with regulatory requirements is a resource-intensive, but critically important activity for medical device manufacturers. This article discusses guidance documents and method of organising technical documentation that may help avoid costly and time-consuming duplication. PMID:16736662

  2. Designing an Algorithm to Preserve Privacy for Medical Record Linkage With Error-Prone Data

    PubMed Central

    Pal, Doyel; Chen, Tingting; Khethavath, Praveen

    2014-01-01

    Background Linking medical records across different medical service providers is important to the enhancement of health care quality and public health surveillance. In records linkage, protecting the patients’ privacy is a primary requirement. In real-world health care databases, records may well contain errors due to various reasons such as typos. Linking the error-prone data and preserving data privacy at the same time are very difficult. Existing privacy preserving solutions for this problem are only restricted to textual data. Objective To enable different medical service providers to link their error-prone data in a private way, our aim was to provide a holistic solution by designing and developing a medical record linkage system for medical service providers. Methods To initiate a record linkage, one provider selects one of its collaborators in the Connection Management Module, chooses some attributes of the database to be matched, and establishes the connection with the collaborator after the negotiation. In the Data Matching Module, for error-free data, our solution offered two different choices for cryptographic schemes. For error-prone numerical data, we proposed a newly designed privacy preserving linking algorithm named the Error-Tolerant Linking Algorithm, that allows the error-prone data to be correctly matched if the distance between the two records is below a threshold. Results We designed and developed a comprehensive and user-friendly software system that provides privacy preserving record linkage functions for medical service providers, which meets the regulation of Health Insurance Portability and Accountability Act. It does not require a third party and it is secure in that neither entity can learn the records in the other’s database. Moreover, our novel Error-Tolerant Linking Algorithm implemented in this software can work well with error-prone numerical data. We theoretically proved the correctness and security of our Error

  3. The centriole duplication cycle.

    PubMed

    Fırat-Karalar, Elif Nur; Stearns, Tim

    2014-09-01

    Centrosomes are the main microtubule-organizing centre of animal cells and are important for many critical cellular and developmental processes from cell polarization to cell division. At the core of the centrosome are centrioles, which recruit pericentriolar material to form the centrosome and act as basal bodies to nucleate formation of cilia and flagella. Defects in centriole structure, function and number are associated with a variety of human diseases, including cancer, brain diseases and ciliopathies. In this review, we discuss recent advances in our understanding of how new centrioles are assembled and how centriole number is controlled. We propose a general model for centriole duplication control in which cooperative binding of duplication factors defines a centriole 'origin of duplication' that initiates duplication, and passage through mitosis effects changes that license the centriole for a new round of duplication in the next cell cycle. We also focus on variations on the general theme in which many centrioles are created in a single cell cycle, including the specialized structures associated with these variations, the deuterosome in animal cells and the blepharoplast in lower plant cells.

  4. The role of frontline RNs in the selection of an electronic medical record business partner.

    PubMed

    Wilhoit, Kathryn; Mustain, Jane; King, Marjorie

    2006-01-01

    Frontline RNs knowledgeable in the strategic objectives of their organization made a difference in the selection of an electronic medical record business partner for a large, complex healthcare system. Their impact was significant because of the chief nurse executive's personal articulation of the organization's strategic goals and of her investment in their education. These factors provided the frontline RNs with a foundational base of knowledge about a variety of electronic medical record systems. The preparation and exposure enabled the frontline RNs to make a valuable contribution to the selection of an electronic medical record business partner. The RNs were a major force in affecting philosophical change from the organization's original pursuit of "best-of-breed" interfaced systems to a fully integrated, "best-of-class" vendor business partner. The learning experiences of the frontline RNs are explored to answer the following question: Why must frontline RNs play a key role in this process? PMID:16849913

  5. The role of frontline RNs in the selection of an electronic medical record business partner.

    PubMed

    Wilhoit, Kathryn; Mustain, Jane; King, Marjorie

    2006-01-01

    Frontline RNs knowledgeable in the strategic objectives of their organization made a difference in the selection of an electronic medical record business partner for a large, complex healthcare system. Their impact was significant because of the chief nurse executive's personal articulation of the organization's strategic goals and of her investment in their education. These factors provided the frontline RNs with a foundational base of knowledge about a variety of electronic medical record systems. The preparation and exposure enabled the frontline RNs to make a valuable contribution to the selection of an electronic medical record business partner. The RNs were a major force in affecting philosophical change from the organization's original pursuit of "best-of-breed" interfaced systems to a fully integrated, "best-of-class" vendor business partner. The learning experiences of the frontline RNs are explored to answer the following question: Why must frontline RNs play a key role in this process?

  6. A patient-controlled journal for an electronic medical record: issues and challenges.

    PubMed

    Wald, Jonathan S; Middleton, Blackford; Bloom, Amy; Walmsley, Dan; Gleason, Mary; Nelson, Elizabeth; Li, Qi; Epstein, Marianna; Volk, Lynn; Bates, David W

    2004-01-01

    Partners Healthcare System, Boston, MA, has developed a patient Web portal that features a patient-controlled electronic "journal" to allow patients to interact with their physician's electronic medical record. Patients can view and respond to health reminders, critique electronic chart information maintained by their doctor's office, enter additional clinical information, and prepare information summaries before an office visit. Creating shared information resources to support a collaborative care model required analysis of the business, architectural, and workflow requirements of the patient-controlled clinical portal and the physician-controlled electronic medical record system. In this paper we describe the challenges in aligning the two systems and serving the different user groups. Coupling the Patient Gateway system, serving over 8700 patients of 90 physicians as of September, 2003, with the Longitudinal Medical Record system, serving over 4000 physicians, has required a clear definition of user goals and workflow, well-defined interfaces, and careful consideration of system assumptions to succeed.

  7. [Design and Implementation of a Mobile Operating Room Information Management System Based on Electronic Medical Record].

    PubMed

    Liu, Baozhen; Liu, Zhiguo; Wang, Xianwen

    2015-06-01

    A mobile operating room information management system with electronic medical record (EMR) is designed to improve work efficiency and to enhance the patient information sharing. In the operating room, this system acquires the information from various medical devices through the Client/Server (C/S) pattern, and automatically generates XML-based EMR. Outside the operating room, this system provides information access service by using the Browser/Server (B/S) pattern. Software test shows that this system can correctly collect medical information from equipment and clearly display the real-time waveform. By achieving surgery records with higher quality and sharing the information among mobile medical units, this system can effectively reduce doctors' workload and promote the information construction of the field hospital. PMID:26485982

  8. [Design and Implementation of a Mobile Operating Room Information Management System Based on Electronic Medical Record].

    PubMed

    Liu, Baozhen; Liu, Zhiguo; Wang, Xianwen

    2015-06-01

    A mobile operating room information management system with electronic medical record (EMR) is designed to improve work efficiency and to enhance the patient information sharing. In the operating room, this system acquires the information from various medical devices through the Client/Server (C/S) pattern, and automatically generates XML-based EMR. Outside the operating room, this system provides information access service by using the Browser/Server (B/S) pattern. Software test shows that this system can correctly collect medical information from equipment and clearly display the real-time waveform. By achieving surgery records with higher quality and sharing the information among mobile medical units, this system can effectively reduce doctors' workload and promote the information construction of the field hospital.

  9. Mining association rules between abnormal health examination results and outpatient medical records.

    PubMed

    Chao Huang, Yi

    2013-01-01

    Currently, interpretation of health examination reports relies primarily on the physician's own experience. If health screening data could be integrated with outpatient medical records to uncover correlations between disease and abnormal test results, the physician could benefit from having additional reference resources for medical examination report interpretation and clinic diagnosis. This study used the medical database of a regional hospital in Taiwan to illustrate how association rules can be found between abnormal health examination results and outpatient illnesses. The rules can help to build up a disease-prevention knowledge database that assists healthcare providers in follow-up treatment and prevention. Furthermore, this study proposes a new algorithm, the data cutting and sorting method, or DCSM, in place of the traditional Apriori algorithm. DCSM significantly improves the mining performance of Apriori by reducing the time to scan health examination and outpatient medical records, both of which are databases of immense sizes.

  10. 76 FR 53921 - Privacy Act of 1974; Department of Homeland Security ALL-034 Emergency Care Medical Records...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-30

    ... employees, their records are considered part of the OPM/GOVT-10--Employee Medical File System Records, 71 FR... considered part of the OPM/GOVT- ] 10--Employee Medical File System Records, 71 FR 35360 (Jun. 19, 2006... SECURITY Office of the Secretary Privacy Act of 1974; Department of Homeland Security ALL--034...

  11. University of Arkansas for Medical Sciences electronic health record and medical informatics training for undergraduate health professionals.

    PubMed

    Hart, Jan K; Newton, Bruce W; Boone, Steven E

    2010-07-01

    The University of Arkansas for Medical Sciences (UAMS) is planning interprofessional training in electronic health records (EHRs) and medical informatics. Training will be integrated throughout the curricula and will include seminars on broad concepts supplemented with online modules, didactic lectures, and hands-on experiences. Training will prepare future health professionals to use EHRs, evidence-based medicine, medical decision support, and point-of-care tools to reduce errors, improve standards of care, address Health Insurance Portability and Accountability Act requirements and accreditation standards, and promote appropriate documentation to enable data retrieval for clinical research. UAMS will ensure that graduates are ready for the rapidly evolving practice environment created by the HITECH Act. PMID:20648253

  12. University of Arkansas for Medical Sciences electronic health record and medical informatics training for undergraduate health professionals*

    PubMed Central

    Hart, Jan K; Newton, Bruce W; Boone, Steven E

    2010-01-01

    The University of Arkansas for Medical Sciences (UAMS) is planning interprofessional training in electronic health records (EHRs) and medical informatics. Training will be integrated throughout the curricula and will include seminars on broad concepts supplemented with online modules, didactic lectures, and hands-on experiences. Training will prepare future health professionals to use EHRs, evidence-based medicine, medical decision support, and point-of-care tools to reduce errors, improve standards of care, address Health Insurance Portability and Accountability Act requirements and accreditation standards, and promote appropriate documentation to enable data retrieval for clinical research. UAMS will ensure that graduates are ready for the rapidly evolving practice environment created by the HITECH Act. PMID:20648253

  13. A study on agent-based secure scheme for electronic medical record system.

    PubMed

    Chen, Tzer-Long; Chung, Yu-Fang; Lin, Frank Y S

    2012-06-01

    Patient records, including doctors' diagnoses of diseases, trace of treatments and patients' conditions, nursing actions, and examination results from allied health profession departments, are the most important medical records of patients in medical systems. With patient records, medical staff can instantly understand the entire medical information of a patient so that, according to the patient's conditions, more accurate diagnoses and more appropriate in-depth treatments can be provided. Nevertheless, in such a modern society with booming information technologies, traditional paper-based patient records have faced a lot of problems, such as lack of uniform formats, low data mobility, slow data transfer, illegible handwritings, enormous and insufficient storage space, difficulty of conservation, being easily damaged, and low transferability. To improve such drawbacks, reduce medical costs, and advance medical quality, paper-based patient records are modified into electronic medical records and reformed into electronic patient records. However, since electronic patient records used in various hospitals are diverse and different, in consideration of cost, it is rather difficult to establish a compatible and complete integrated electronic patient records system to unify patient records from heterogeneous systems in hospitals. Moreover, as the booming of the Internet, it is no longer necessary to build an integrated system. Instead, doctors can instantly look up patients' complete information through the Internet access to electronic patient records as well as avoid the above difficulties. Nonetheless, the major problem of accessing to electronic patient records cross-hospital systems exists in the security of transmitting and accessing to the records in case of unauthorized medical personnels intercepting or stealing the information. This study applies the Mobile Agent scheme to cope with the problem. Since a Mobile Agent is a program, which can move among hosts and

  14. The computerized medical record in gastroenterology: part 4. Health curriculum vitae.

    PubMed

    Jeanty, C

    1978-12-01

    The health curriculum vitae consists mainly of a chronological sequence of diagnoses, which are the mainstays of the medical record. Each diagnosis is connected vertically in the health curriculum vitae with its aetiological factors and its medical or surgical treatments in a casual concatenation; and horizontally throughout the other three parts of the record with its relevant functional, morphological (descriptive) and numerical laboratory data in a diagnostic association. The health curriculum vitae uses the Systematized Nomenclature of Medicine (SNOMED), the International Nomenclature of the Diseases of the Gastrointestinal Tract (CIOMS) and the International Standard Classification of Occupations of the Internationl Labour Office.

  15. Focusing on Patient Safety: the Challenge of Securely Sharing Electronic Medical Records in Complex Care Continuums.

    PubMed

    Key, Diana; Ferneini, Elie M

    2015-09-01

    The Patient Protection and Affordable Care Act's (PPACA) regulated approach to inclusive provision of care will increase the challenge health care administrators face ensuring secure communication and secure sharing of electronic medical records between divisions and care subcontractors. This analysis includes a summary overview of the PPACA; the Health Care and Education Reconciliation Act (HCERA) of 2010; and required Essential Health Benefits (EHB). The analysis integrates an overview of how secure communication and secure sharing of electronic medical records will be essential to clinical outcomes across complex care continuums; as well as the actionable strategies health care leadership can employ to overcome associated IT security challenges.

  16. FRR: fair remote retrieval of outsourced private medical records in electronic health networks.

    PubMed

    Wang, Huaqun; Wu, Qianhong; Qin, Bo; Domingo-Ferrer, Josep

    2014-08-01

    Cloud computing is emerging as the next-generation IT architecture. However, cloud computing also raises security and privacy concerns since the users have no physical control over the outsourced data. This paper focuses on fairly retrieving encrypted private medical records outsourced to remote untrusted cloud servers in the case of medical accidents and disputes. Our goal is to enable an independent committee to fairly recover the original private medical records so that medical investigation can be carried out in a convincing way. We achieve this goal with a fair remote retrieval (FRR) model in which either t investigation committee members cooperatively retrieve the original medical data or none of them can get any information on the medical records. We realize the first FRR scheme by exploiting fair multi-member key exchange and homomorphic privately verifiable tags. Based on the standard computational Diffie-Hellman (CDH) assumption, our scheme is provably secure in the random oracle model (ROM). A detailed performance analysis and experimental results show that our scheme is efficient in terms of communication and computation.

  17. An electronic health record driven algorithm to identify incident antidepressant medication users

    PubMed Central

    Bobo, William V; Pathak, Jyotishman; Kremers, Hilal Maradit; Yawn, Barbara P; Brue, Scott M; Stoppel, Cynthia J; Croarkin, Paul E; St Sauver, Jennifer; Frye, Mark A; Rocca, Walter A

    2014-01-01

    Objective We validated an algorithm designed to identify new or prevalent users of antidepressant medications via population-based drug prescription records. Patients and methods We obtained population-based drug prescription records for the entire Olmsted County, Minnesota, population from 2011 to 2012 (N=149 629) using the existing electronic medical records linkage infrastructure of the Rochester Epidemiology Project (REP). We selected electronically a random sample of 200 new antidepressant users stratified by age and sex. The algorithm required the exclusion of antidepressant use in the 6 months preceding the date of the first qualifying antidepressant prescription (index date). Medical records were manually reviewed and adjudicated to calculate the positive predictive value (PPV). We also manually reviewed the records of a random sample of 200 antihistamine users who did not meet the case definition of new antidepressant user to estimate the negative predictive value (NPV). Results 161 of the 198 subjects electronically identified as new antidepressant users were confirmed by manual record review (PPV 81.3%). Restricting the definition of new users to subjects who were prescribed typical starting doses of each agent for treating major depression in non-geriatric adults resulted in an increase in the PPV (90.9%). Extending the time windows with no antidepressant use preceding the index date resulted in only modest increases in PPV. The manual abstraction of medical records of 200 antihistamine users yielded an NPV of 98.5%. Conclusions Our study confirms that REP prescription records can be used to identify prevalent and incident users of antidepressants in the Olmsted County, Minnesota, population. PMID:24780720

  18. Interstitial duplication 19p

    SciTech Connect

    Stratton, R.F.; DuPont, B.R.; Moore, C.M.

    1995-07-17

    We report on a 9-month-old girl with an interstitial duplication of 19p, developmental delay, and multiple anomalies including bifrontal prominence, obtuse frontonasal angle, short columella, additional midline philtral pillar, midline ridge on the tongue, vertical midline ridge at the mental symphysis, and a complex congenital heart defect including severe branch pulmonary artery stenosis, secundum atrial septal defect (ASD), and several ventricular septal defects (VSDs). Use of fluorescent in situ hybridization (FISH) with chromosome 19- specific probes showed a direct duplication of bands 19p13.13 and 19p13.2. 6 refs., 1 fig.

  19. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 10 Energy 1 2011-01-01 2011-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  20. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 1 2014-01-01 2014-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  1. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 10 Energy 1 2012-01-01 2012-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  2. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  3. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 10 Energy 1 2013-01-01 2013-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  4. The evolution of office notes and the electronic medical record: The CAPS note.

    PubMed

    Styron, Joseph F; Evans, Peter J

    2016-07-01

    The advent of the electronic medical record (EMR) combined with an expansion of information required by medicolegal and billing departments has transformed the progress note from a succinct note into an often unwieldy data-dump unable to concisely convey the physician's medical reasoning. We describe a new note format--CAPS, which stands for concern, assessment, plan, and supporting data--to streamline the communication of the patient's problem, the practitioner's assessment and plan, and the medical reasoning to support the plan. PMID:27399867

  5. Dual function seal: visualized digital signature for electronic medical record systems.

    PubMed

    Yu, Yao-Chang; Hou, Ting-Wei; Chiang, Tzu-Chiang

    2012-10-01

    Digital signature is an important cryptography technology to be used to provide integrity and non-repudiation in electronic medical record systems (EMRS) and it is required by law. However, digital signatures normally appear in forms unrecognizable to medical staff, this may reduce the trust from medical staff that is used to the handwritten signatures or seals. Therefore, in this paper we propose a dual function seal to extend user trust from a traditional seal to a digital signature. The proposed dual function seal is a prototype that combines the traditional seal and digital seal. With this prototype, medical personnel are not just can put a seal on paper but also generate a visualized digital signature for electronic medical records. Medical Personnel can then look at the visualized digital signature and directly know which medical personnel generated it, just like with a traditional seal. Discrete wavelet transform (DWT) is used as an image processing method to generate a visualized digital signature, and the peak signal to noise ratio (PSNR) is calculated to verify that distortions of all converted images are beyond human recognition, and the results of our converted images are from 70 dB to 80 dB. The signature recoverability is also tested in this proposed paper to ensure that the visualized digital signature is verifiable. A simulated EMRS is implemented to show how the visualized digital signature can be integrity into EMRS.

  6. Evaluation of Unpreparedness When Issuing Copies of Medical Records in Tertiary Referral Hospitals

    PubMed Central

    Moon, Myong-Mo; Seo, Sun-Won; Park, Woo-Sung; Kim, Yoon; Kim, Sung-Soo; Choi, Eun-Mi; Park, Jong; Park, Il-Soon

    2010-01-01

    Objectives As a baseline study to aid in the development of proper policy, we investigated the current condition of unpreparedness of documents required when issuing copies of medical records and related factors. Methods The study was comprised of 7,203 cases in which copies of medical records were issued from July 1st, 2007 through June 30th, 2008 to 5 tertiary referral hospitals. Data from these hospitals was collected using their established electronic databases and included study variables such as unpreparedness of the required documents as a dependent variable and putative covariates. Results The rate of unpreparedness of required documents was 14.9%. Multiple logistic regression analysis revealed the following factors as being related to the high rate of unpreparedness: patient age (older patients had a higher rate), issuance channels (on admission > via out-patient clinic), type of applicant (others such as family members > for oneself > insurers), type of original medical record (utilization records on admission > other records), issuance purpose (for providing insurer > medical use), residential area of applicant (Seoul > Honam province and Jeju), and number of copied documents (more documents gave a lower rate). The rate of unpreparedness differed significantly among the hospitals; suggesting that they may have followed their own conventional protocols rather than legal procedures in some cases. Conclusions The study results showed that the level of compliance to the required legal procedure was high, but that problems occurred in assuring the safety of the medical information. A proper legislative approach is therefore required to balance the security of and access to medical information. PMID:21818431

  7. [A method for auditing medical records quality: audit of 467 medical records within the framework of the medical information systems project quality control].

    PubMed

    Boulay, F; Chevallier, T; Gendreike, Y; Mailland, V; Joliot, Y; Sambuc, R

    1998-03-01

    Future hospital accreditation could take into account the quality of medical files. The objectives of this study is to test a method for auditing and evaluating the quality of the handing of medical files. We conducted a retrospective regional audit based on the frame of reference the National Agency for Medical Development and Evaluation, by using a sample of cases, stratified by establishment. In our region, the global budgets of 47 public and private hospitals participating in the public hospital service, are adjusted while keeping in mind the medicalised activity data (PMSI). This audit was proposed to the doctors of the Department of Medical Information on the occasion of the regulatory PMSI quality control. A total of 467 questionnaires were given by 39 of the 47 sollicited hospitals (83%). The methodological aspects (questionnaire, cooperative approach...) are discussed. The make-up of medical files can alos be improved by raising the percentage of the presence of important data or documents such as the reason for admission (74.1%), the surgery report (83.2%), and the hospitalisation report (66.6%). A system for classifying the paraclinical results is shared and systematic throughout the service or hospital in only 73.2% of cases. The quality of the handing of medical files seems problematic in our hospitals and actions for improving the quality should be undertaken as a priority. PMID:9685806

  8. A SWOT Analysis of the Various Backup Scenarios Used in Electronic Medical Record Systems

    PubMed Central

    Seo, Hwa Jeong; Kim, Hye Hyeon

    2011-01-01

    Objectives Electronic medical records (EMRs) are increasingly being used by health care services. Currently, if an EMR shutdown occurs, even for a moment, patient safety and care can be seriously impacted. Our goal was to determine the methodology needed to develop an effective and reliable EMR backup system. Methods Our "independent backup system by medical organizations" paradigm implies that individual medical organizations develop their own EMR backup systems within their organizations. A "personal independent backup system" is defined as an individual privately managing his/her own medical records, whereas in a "central backup system by the government" the government controls all the data. A "central backup system by private enterprises" implies that individual companies retain control over their own data. A "cooperative backup system among medical organizations" refers to a networked system established through mutual agreement. The "backup system based on mutual trust between an individual and an organization" means that the medical information backup system at the organizational level is established through mutual trust. Results Through the use of SWOT analysis it can be shown that cooperative backup among medical organizations is possible to be established through a network composed of various medical agencies and that it can be managed systematically. An owner of medical information only grants data access to the specific person who gave the authorization for backup based on the mutual trust between an individual and an organization. Conclusions By employing SWOT analysis, we concluded that a linkage among medical organizations or between an individual and an organization can provide an efficient backup system. PMID:22084811

  9. Current Duplicating Processes

    ERIC Educational Resources Information Center

    Groneman, Nancy

    1978-01-01

    While business instructors are still teaching spirit and stencil duplicating processes, most businesses now use copiers or offset printing processes. The article discusses offset and copier skills needed by office workers, pointing out that the processes being taught should be compatible with those used in business. (MF)

  10. Perspectives on Program Duplication

    ERIC Educational Resources Information Center

    Morrison, Gail M.

    2010-01-01

    Concerns about program duplication in higher education are often reminiscent of Supreme Court Justice Potter Stewart's now famous remark about pornography: "I know it when I see it." The problem with that reaction is that, at least on its surface, this response seems intuitive and emotional, to say nothing of subjective and personal. The fact is…

  11. The centriole duplication cycle

    PubMed Central

    Fırat-Karalar, Elif Nur; Stearns, Tim

    2014-01-01

    Centrosomes are the main microtubule-organizing centre of animal cells and are important for many critical cellular and developmental processes from cell polarization to cell division. At the core of the centrosome are centrioles, which recruit pericentriolar material to form the centrosome and act as basal bodies to nucleate formation of cilia and flagella. Defects in centriole structure, function and number are associated with a variety of human diseases, including cancer, brain diseases and ciliopathies. In this review, we discuss recent advances in our understanding of how new centrioles are assembled and how centriole number is controlled. We propose a general model for centriole duplication control in which cooperative binding of duplication factors defines a centriole ‘origin of duplication’ that initiates duplication, and passage through mitosis effects changes that license the centriole for a new round of duplication in the next cell cycle. We also focus on variations on the general theme in which many centrioles are created in a single cell cycle, including the specialized structures associated with these variations, the deuterosome in animal cells and the blepharoplast in lower plant cells. PMID:25047614

  12. Duplication Is Ubiquitous

    ERIC Educational Resources Information Center

    Tenopir, Carol

    2005-01-01

    This article discusses how Phil Davis, Life Sciences Bibliographer at Cornell University, found duplicate articles in Emerald/MCB University Press journals. According to Davis, he has found hundreds of examples of the same article published in more than one journal in at least 73 Emerald/MCB journals over 30 years. This article gives the details…

  13. Medical Individualism or Medical Familism? A Critical Analysis of China's New Guidelines for Informed Consent: The Basic Norms of the Documentation of the Medical Record.

    PubMed

    Bian, Lin

    2015-08-01

    Modern Western medical individualism has had a significant impact on health care in China. This essay demonstrates the ways in which such Western-style individualism has been explicitly endorsed in China's 2010 directive: The Basic Norms of the Documentation of the Medical Record. The Norms require that the patient himself, rather than a member of his family, sign each informed consent form. This change in clinical practice indicates a shift toward medical individualism in Chinese healthcare legislation. Such individualism, however, is incompatible with the character of Chinese familism that is deeply rooted in the Chinese ethical tradition. It also contradicts family-based patterns of health care in China. Moreover, the requirement for individual informed consent is incompatible with numerous medical regulations promulgated in the past two decades. This essay argues that while Chinese medical legislation should learn from relevant Western ideas, it should not simply copy such practices by importing medical individualism into Chinese health care. Chinese healthcare policy is properly based on Chinese medical familist resources. PMID:26070661

  14. Medical Individualism or Medical Familism? A Critical Analysis of China's New Guidelines for Informed Consent: The Basic Norms of the Documentation of the Medical Record.

    PubMed

    Bian, Lin

    2015-08-01

    Modern Western medical individualism has had a significant impact on health care in China. This essay demonstrates the ways in which such Western-style individualism has been explicitly endorsed in China's 2010 directive: The Basic Norms of the Documentation of the Medical Record. The Norms require that the patient himself, rather than a member of his family, sign each informed consent form. This change in clinical practice indicates a shift toward medical individualism in Chinese healthcare legislation. Such individualism, however, is incompatible with the character of Chinese familism that is deeply rooted in the Chinese ethical tradition. It also contradicts family-based patterns of health care in China. Moreover, the requirement for individual informed consent is incompatible with numerous medical regulations promulgated in the past two decades. This essay argues that while Chinese medical legislation should learn from relevant Western ideas, it should not simply copy such practices by importing medical individualism into Chinese health care. Chinese healthcare policy is properly based on Chinese medical familist resources.

  15. 75 FR 1625 - Privacy Act of 1974; Report of Amended or Altered System; Medical, Health and Billing Records System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-12

    ... (EKG) tapes. 6. Third-party reimbursement and billing records containing name, address, date of birth..., EEG and EKG tapes) that are not stored in the individual's official medical record are stored at...

  16. 29 CFR 1915.1020 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 7 2010-07-01 2010-07-01 false Access to employee exposure and medical records. 1915.1020 Section 1915.1020 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR (CONTINUED) OCCUPATIONAL SAFETY AND HEALTH STANDARDS FOR SHIPYARD...

  17. 29 CFR 1915.1020 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 29 Labor 7 2011-07-01 2011-07-01 false Access to employee exposure and medical records. 1915.1020 Section 1915.1020 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR (CONTINUED) OCCUPATIONAL SAFETY AND HEALTH STANDARDS FOR SHIPYARD...

  18. Developing a Systematic Architecture Approach for Designing an Enhanced Electronic Medical Record (EEMR) System

    ERIC Educational Resources Information Center

    Aldukheil, Maher A.

    2013-01-01

    The Healthcare industry is characterized by its complexity in delivering care to the patients. Accordingly, healthcare organizations adopt and implement Information Technology (IT) solutions to manage complexity, improve quality of care, and transform to a fully integrated and digitized environment. Electronic Medical Records (EMR), which is…

  19. Worth a thousand words: Integrating clinical photographs into an electronic medical record.

    PubMed

    Beard, H R; Hamid, K S

    2014-03-01

    Technological advances have made clinical photographs ubiquitous but the tremendous value of images is often burdened by concerns that are both legitimate and unsubstantiated. Compliant photos dramatically improve patient value and should be encouraged after adequate institutional preparation. As healthcare networks continue to transition to electronic medical records, clinicians and administrators should outline reasonable policies to integrate photos safely.

  20. 32 CFR 1901.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... records. 1901.31 Section 1901.31 National Defense Other Regulations Relating to National Defense CENTRAL INTELLIGENCE AGENCY PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters § 1901.31... not exempt from disclosure, the Agency will, after consultation with the Director of Medical...

  1. 32 CFR 1901.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... records. 1901.31 Section 1901.31 National Defense Other Regulations Relating to National Defense CENTRAL INTELLIGENCE AGENCY PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters § 1901.31... not exempt from disclosure, the Agency will, after consultation with the Director of Medical...

  2. 32 CFR 1901.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... records. 1901.31 Section 1901.31 National Defense Other Regulations Relating to National Defense CENTRAL INTELLIGENCE AGENCY PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters § 1901.31... not exempt from disclosure, the Agency will, after consultation with the Director of Medical...

  3. 32 CFR 1901.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... records. 1901.31 Section 1901.31 National Defense Other Regulations Relating to National Defense CENTRAL INTELLIGENCE AGENCY PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters § 1901.31... not exempt from disclosure, the Agency will, after consultation with the Director of Medical...

  4. 32 CFR 1901.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... records. 1901.31 Section 1901.31 National Defense Other Regulations Relating to National Defense CENTRAL INTELLIGENCE AGENCY PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters § 1901.31... not exempt from disclosure, the Agency will, after consultation with the Director of Medical...

  5. Health Care Professionals' Perceptions of the Use of Electronic Medical Records

    ERIC Educational Resources Information Center

    Adeyeye, Adebisi

    2015-01-01

    Electronic medical record (EMR) use has improved significantly in health care organizations. However, many barriers and factors influence the success of EMR implementation and adoption. The purpose of the descriptive qualitative single-case study was to explore health care professionals' perceptions of the use of EMRs at a hospital division of a…

  6. 75 FR 1446 - Rate of Payment for Medical Records Received Through Health Information Technology (IT) Necessary...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-11

    ... ADMINISTRATION Rate of Payment for Medical Records Received Through Health Information Technology (IT) Necessary... Supplemental Security Income (SSI) payments on the basis of disability, and we expect this trend to continue..., underscores our need to process cases more efficiently by using advanced technologies. Applicants...

  7. Strategies Nurse Managers Used to Offset Challenges during Electronic Medical Records Implementation: A Case Study

    ERIC Educational Resources Information Center

    Easterling, Latasha

    2015-01-01

    The purpose of this qualitative, descriptive case study was to discover successful approaches used, by nurse managers, to reduce barriers during the implementation of electronic medical record system in one hospital. Fourteen nurse managers were interviewed from an academic health science center in Mississippi. A pilot study was conducted to…

  8. 49 CFR 382.409 - Medical review officer record retention for controlled substances.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 49 Transportation 5 2013-10-01 2013-10-01 false Medical review officer record retention for controlled substances. 382.409 Section 382.409 Transportation Other Regulations Relating to Transportation... notifications, identified by individual, for a minimum of five years for verified positive controlled...

  9. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... (overseas), the age of majority is 18. Unless parents or guardians have a court order granting access or the minor's written consent, they will not have access to minor's medical records overseas when the minor sought or consented to treatment between the ages of 15 and 17 in a program where regulation or...

  10. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... (overseas), the age of majority is 18. Unless parents or guardians have a court order granting access or the minor's written consent, they will not have access to minor's medical records overseas when the minor sought or consented to treatment between the ages of 15 and 17 in a program where regulation or...

  11. Are Persons Reporting "Near-Death Experiences" Really Near Death? A Study of Medical Records.

    ERIC Educational Resources Information Center

    Stevenson, Ian; And Others

    1990-01-01

    Examination of medical records from 40 patients who reported unusual experiences during an illness or injury revealed that only 18 patients were judged to have had serious, life-threatening conditions, while 33 believed they had been dead or near death. Findings suggest that an important precipitator of so-called near-death experience is belief…

  12. Student nurses and the electronic medical record: a partnership of academia and healthcare.

    PubMed

    Bowers, Anna Mary; Kavanagh, Joan; Gregorich, Tom; Shumway, Julia; Campbell, Yolanda; Stafford, Susan

    2011-12-01

    The advent of the electronic medical record has brought a new challenge to nursing education. Although most nursing students are proficient in data entry and computer skills, they often do not comprehend how the information they enter becomes a vital component of interdisciplinary team communication. Furthermore, the electronic medical record becomes a repository for information that can be retrieved for the purpose of decision support. Developed by the Cleveland Clinic, the Deans' Roundtable, and University Hospitals of Cleveland, the Student Nurse Portal provides a means of assisting the student to understand how data entered into the computer transforms into information and knowledge, resulting in the wisdom that enables healthcare workers to provide optimal patient care. Current courses present the purpose of the electronic medical record and its roleas a powerful communication tool, but future courses will also help the student develop data entry and retrieval skills. Hosted on the Cleveland Clinic servers and available to students around-the-clock from any computer with Internet access, students have found the Student Nurse Portal to be a valuable tool in preparing for the use of the electronic medical record during their clinical experiences.

  13. Evolution of Medication Administration Workflow in Implementing Electronic Health Record System

    ERIC Educational Resources Information Center

    Huang, Yuan-Han

    2013-01-01

    This study focused on the clinical workflow evolutions when implementing the health information technology (HIT). The study especially emphasized on administrating medication when the electronic health record (EHR) systems were adopted at rural healthcare facilities. Mixed-mode research methods, such as survey, observation, and focus group, were…

  14. Electronic Medical Records Adoption and Usage among Osteopathic Physicians in New York State

    ERIC Educational Resources Information Center

    Rosenthal, Jon I.

    2012-01-01

    In 2010, the U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology reported a slow rate of adoption of electronic medical records. The present research sought to explore possible reasons for this situation by examining factors that distinguished between users and nonusers of electronic…

  15. 7 CFR 110.5 - Availability of records to facilitate medical treatment.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 7 Agriculture 3 2014-01-01 2014-01-01 false Availability of records to facilitate medical treatment. 110.5 Section 110.5 Agriculture Regulations of the Department of Agriculture (Continued) AGRICULTURAL MARKETING SERVICE (Standards, Inspections, Marketing Practices), DEPARTMENT OF AGRICULTURE (CONTINUED) COMMODITY LABORATORY TESTING...

  16. 32 CFR 1801.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 6 2011-07-01 2011-07-01 false Special procedures for medical and psychological records. 1801.31 Section 1801.31 National Defense Other Regulations Relating to National Defense NATIONAL... the identity of the physician, and agreement by the physician: (1) To review the documents with...

  17. An Evaluation of Authentic Learning in an Electronic Medical Records System

    ERIC Educational Resources Information Center

    Stuart, Sandra L.

    2013-01-01

    This study examined participants' perceptions of the effectiveness of a new job-training program designed to enhance the authentic learning in adult learners using an electronic medical records system at a naval health clinic. This job-training program lacked data about participants' perceptions of this learning process by which to gauge its…

  18. A real time Teleconsultation System for Sharing an Oncologic Web-based Electronic Medical Record.

    PubMed

    Forti, Stefano; Galvagni, Michele; Galligioni, Enzo; Eccher, Claudio

    2005-01-01

    This poster presents an innovative real-time Teleconsultation System for synchronized navigation of the pages of a web-based Oncological Electronic Medical Record, designed to provide clinicians a cooperative work tool supporting the oncologic patient management between different hospitals. The system embeds additional tools supporting the discussion: digital whiteboard, chat and a digital audio channel.

  19. Organizational Leader Sensemaking in Healthcare Process Changes: The Development of the Electronic Medical Records Expectation Questionnaire

    ERIC Educational Resources Information Center

    Riesenmy, Kelly Rouse

    2011-01-01

    Physicians play a unique role in the adoption of electronic medical records (EMR) within the healthcare organization. As leaders, they are responsible for setting the standards for this new technology within their sphere of influence while concurrently being required to learn and integrate EMR into their own workflow and process as the recipients…

  20. Giving patients secure < Google-like > access to their medical record.

    PubMed

    Quantin, Catherine; Fassa, Maniane; Coatrieux, Gouenou; Breton, Vincent; Boire, Jean Yves; Allaert, François André

    2008-01-01

    The main problem for the patient who wants to have access to all of the information about his health is that this information is very often spread over many medical records. Therefore, it would be convenient for the patient, after being identified and authenticated, to use a kind of specific medical search engine as one part of the solution to this main problem. The principal objective is for the patient to have access to his or her medical information at anytime and wherever it has been stored. This proposal for secure "Google Like" access requires the addition of different conditions: very strict identity checks using cryptographic techniques such as those planned for the electronic signature, which will not only ensure authentication of the patient and integrity of the file, but also protection of the confidentiality and access follow-up. The electronic medical record must also be electronically signed by the practitioner in order to provide evidence that he has given his agreement and accepted responsibility for the content. This electronic signature also prevents any kind of post-transmission falsification. New advances in technology make it possible to envisage access to medical records anywhere and anytime, thanks to Grid and watermarking methodologies.

  1. Performance improvement indicators of the Medical Records Department and Information Technology (IT) in hospitals

    PubMed Central

    Ajami, Sima; Ketabi, Saedeh; Torabiyan, Fatemeh

    2015-01-01

    Medical Record Department (MRD) has a vital role in making short and long term plans to improve health system services. The aim of this study was to describe performance improvement indicators of hospital MRD and information technology (IT). Collection of Data: A search was conducted in various databases, through related keywords in articles, books, and abstracts of conferences from 2001 to 2009. About 58 articles and books were available which were evaluated and finally 15 of them were selected based on their relevance to the study. MRD must be capable of supporting tasks such as patient care and continuity, institute management processes, medical education programs, medical research, communication between different wards of a hospital and administrative and medical staff. The use of IT in MRD can facilitate access to department, expedite communication within and outside department, reduce space with electronic medical records, reduce costs, accelerate activities such as coding by use of coding guide software and facilitate retrieval of records that will ultimately improve the performance of MRD. PMID:26150874

  2. Genomic data in the electronic medical record: perspectives from a biobank community advisory board.

    PubMed

    Kimball, Brittany C; Nowakowski, Katherine E; Maschke, Karen J; McCormick, Jennifer B

    2014-12-01

    A proof of principle pharmacogenomic translational study was used as a case example to explore Biobank Community Advisory Board (CAB) member views about placing genomic information into the medical record and to establish how CAB input could affect research design. CAB members expressed enthusiasm for the potential benefit of the research discussed, yet voiced concerns regarding the recruitment and consent materials. They discussed the value of genomic research and its clinical utility; the risk of genetic discrimination; and personal ownership of genomic data. Members distinguished between indirect benefits to future generations and individual risk to research participants. Feedback was used to revise the recruitment and consent materials. Results highlight tensions reported between the public's support for genomic research and concerns with genomic information in the medical record and its use in medical decision-making.

  3. A Proposal for Electronic Medical Records in U.S. Primary Care

    PubMed Central

    Bates, David W.; Ebell, Mark; Gotlieb, Edward; Zapp, John; Mullins, H.C.

    2003-01-01

    Delivery of excellent primary care—central to overall medical care—demands that providers have the necessary information when they give care. This paper, developed by the National Alliance for Primary Care Informatics, a collaborative group sponsored by a number of primary care societies, argues that providers’ and patients’ information and decision support needs can be satisfied only if primary care providers use electronic medical records (EMRs). Although robust EMRs are now available, only about 5% of U.S. primary care providers use them. Recently, with only modest investments, Australia, New Zealand, and England have achieved major breakthroughs in implementing EMRs in primary care. Substantial benefits realizable through routine use of electronic medical records include improved quality, safety, and efficiency, along with increased ability to conduct education and research. Nevertheless, barriers to adoption exist and must be overcome. Implementing specific policies can accelerate utilization of EMRs in the U.S. PMID:12509352

  4. Patients want granular privacy control over health information in electronic medical records

    PubMed Central

    Caine, Kelly; Hanania, Rima

    2013-01-01

    Objective To assess patients’ desire for granular level privacy control over which personal health information should be shared, with whom, and for what purpose; and whether these preferences vary based on sensitivity of health information. Materials and methods A card task for matching health information with providers, questionnaire, and interview with 30 patients whose health information is stored in an electronic medical record system. Most patients’ records contained sensitive health information. Results No patients reported that they would prefer to share all information stored in an electronic medical record (EMR) with all potential recipients. Sharing preferences varied by type of information (EMR data element) and recipient (eg, primary care provider), and overall sharing preferences varied by participant. Patients with and without sensitive records preferred less sharing of sensitive versus less-sensitive information. Discussion Patients expressed sharing preferences consistent with a desire for granular privacy control over which health information should be shared with whom and expressed differences in sharing preferences for sensitive versus less-sensitive EMR data. The pattern of results may be used by designers to generate privacy-preserving EMR systems including interfaces for patients to express privacy and sharing preferences. Conclusions To maintain the level of privacy afforded by medical records and to achieve alignment with patients’ preferences, patients should have granular privacy control over information contained in their EMR. PMID:23184192

  5. A comparison of self-reported colorectal cancer screening with medical records.

    PubMed

    Madlensky, Lisa; McLaughlin, John; Goel, Vivek

    2003-07-01

    The purpose of this study was to compare self-reports of colorectal cancer (CRC) screening by fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy with medical records in a multiprovider health care setting. Relatives of CRC patients residing in Ontario, Canada completed a questionnaire indicating whether or not they had ever had any CRC screening tests. Medical records from physician's offices and hospitals were compared with the self reports, and where possible, reasons were obtained for nonmatching reports. Medical records for colonoscopies were readily available from various sources, and self-reports of this procedure were very accurate (kappa statistic for agreement beyond chance = 0.87). For sigmoidoscopy and FOBT, the agreement was poorer (kappa = 0.29 and 0.32, respectively); however, there were difficulties in obtaining records for these two procedures. Sigmoidoscopy procedures that took place many years ago were difficult to document, and physician's offices were unable to provide FOBT reports in many cases. Self-reports of colonoscopy were very accurate in this population, whereas self-reports of sigmoidoscopy and FOBT are somewhat less accurate, although this is likely due to challenges in obtaining a confirmatory record rather than an overreporting of tests. In a multiprovider publicly insured health care setting such as Canada, using self-reported information is likely to provide sufficiently accurate information for colonoscopy, but for other CRC screening tests, there may be difficulty in obtaining true estimates of the frequencies of these procedures. PMID:12869407

  6. Formal representation of a conceptual data model for the patient-based medical record.

    PubMed

    Gouveia-Oliveira, A; Lopes, L

    1993-01-01

    We present a general architecture for the patient-based medical record as it is being developed for the SAMS, a private social security system. The conceptual data model is described in a convenient formal notation, the entity-relationship diagram. Although following the original formulation of the problem-oriented medical record (POMR), the data model was designed with a level of generalization that, functionally, makes structural differences between conventional and POMR no longer apparent. The main features of this model are its adaptability to individual work practices and its problem-oriented structure, including the representation of problems' evolution. This structure will enable physicians to organize the data, mostly collected elsewhere, by explicitly relating the facts that constitute a particular patient record, which is a simple way to store context information and clinical knowledge that is not part of patient data.

  7. Distribution of Problems, Medications and Lab Results in Electronic Health Records: The Pareto Principle at Work

    PubMed Central

    Wright, Adam; Bates, David W.

    2010-01-01

    Background Many natural phenomena demonstrate power-law distributions, where very common items predominate. Problems, medications and lab results represent some of the most important data elements in medicine, but their overall distribution has not been reported. Objective Our objective is to determine whether problems, medications and lab results demonstrate a power law distribution. Methods Retrospective review of electronic medical record data for 100,000 randomly selected patients seen at least twice in 2006 and 2007 at the Brigham and Women’s Hospital in Boston and its affiliated medical practices. Results All three data types exhibited a power law distribution. The 12.5% most frequently used problems account for 80% of all patient problems, the top 11.8% of medications account for 80% of all medication orders and the top 4.5% of lab result types account for all lab results. Conclusion These three data elements exhibited power law distributions with a small number of common items representing a substantial proportion of all orders and observations, which has implications for electronic health record design. PMID:21991298

  8. New advanced technologies to provide decentralised and secure access to medical records: case studies in oncology.

    PubMed

    Quantin, Catherine; Coatrieux, Gouenou; Allaert, François André; Fassa, Maniane; Bourquard, Karima; Boire, Jean-Yves; de Vlieger, Paul; Maigne, Lydia; Breton, Vincent

    2009-08-07

    The main problem for health professionals and patients in accessing information is that this information is very often distributed over many medical records and locations. This problem is particularly acute in cancerology because patients may be treated for many years and undergo a variety of examinations. Recent advances in technology make it feasible to gain access to medical records anywhere and anytime, allowing the physician or the patient to gather information from an "ephemeral electronic patient record". However, this easy access to data is accompanied by the requirement for improved security (confidentiality, traceability, integrity, ...) and this issue needs to be addressed. In this paper we propose and discuss a decentralised approach based on recent advances in information sharing and protection: Grid technologies and watermarking methodologies. The potential impact of these technologies for oncology is illustrated by the examples of two experimental cases: a cancer surveillance network and a radiotherapy treatment plan. It is expected that the proposed approach will constitute the basis of a future secure "google-like" access to medical records.

  9. Attitudes of First-year Medical Students Toward the Confidentiality of Computerized Patient Records

    PubMed Central

    Davis, Luke; Domm, Jennifer A.; Konikoff, Michael R.; Miller, Randolph A.

    1999-01-01

    Objectives: To investigate the attitudes of students entering medical school toward the confidentiality of computerized medical records. Design: First-year medical students at the Vanderbilt University School of Medicine responded to a series of questions about a hypothetic breach of patient's privacy through a computerized patient record system. Measurements: The individual authors independently grouped the blinded responses according to whether they were consistent with then-current institutional policy. These preliminary groupings were discussed, and final categorizations were made by consensus. Results: While most students had a sense of what was right and wrong in absolute terms, half the class suggested at least one course of action that was deemed to be inconsistent with institutional policies. Conclusions: The authors believe that medical schools should directly address ethical and legal issues related to the use of computers in clinical practice as an integral part of medical school curricula. Several teaching approaches can facilitate a greater awareness of the issues surrounding technology and medicine. PMID:9925228

  10. Improving the Effectiveness of Physiology Record Books as a Learning Tool for First-Year Medical Students in India

    ERIC Educational Resources Information Center

    Vyas, Rashmi; Tharion, Elizabeth; Sathishkumar, Solomon

    2009-01-01

    In compliance with the Medical Council of India, preclinical medical students maintain a record of their laboratory work in physiology. The physiology record books also contain a set of questions to be answered by the students. Faculty members and students had indicated that responding to these questions did not serve the intended purpose of being…

  11. Assessment of the Need to Integrate Academic Electronic Medical Records Into the Undergraduate Clinical Practicum: A Focus Group Interview.

    PubMed

    Choi, Mona; Park, Joon Ho; Lee, Hyeong Suk

    2016-06-01

    As healthcare systems demand that nurses be competent in using electronic medical records for patient care, the integration of electronic medical records into nursing curricula has become necessary. The purpose of this study was to explore how students, new nurses, clinical instructors, and faculty perceive the integration of academic electronic medical records into the undergraduate clinical practicum. From January to February 2014, four focus group interviews with 18 participants were conducted based on purposive sampling. Content analysis was used on the unabridged transcripts to extract themes and develop meaningful categories. Three major themes and eight subthemes were revealed from the focus group interviews. The major themes were "electronic medical record as a learning tool for clinical practicum," "essential functions of academic electronic medical records," and "expected outcomes of academic electronic medical record." Participants expected academic electronic medical records to enhance students' nursing informatics competencies. The findings of this study can inform the process of developing academic electronic medical records for clinical practicum, which will then augment students' informatics competencies. PMID:27081757

  12. 5 CFR 875.103 - Do I need to authorize release of my medical records when I file a claim?

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... Administration and General Provisions § 875.103 Do I need to authorize release of my medical records when I file a claim? Yes, if you file a claim for benefits, the Carrier needs to have a valid authorization from... medical records when I file a claim? 875.103 Section 875.103 Administrative Personnel OFFICE OF...

  13. The intelligent use and clinical benefits of electronic medical records in multiple sclerosis

    PubMed Central

    Davis, Mary F.

    2015-01-01

    Summary Electronic medical records (EMRs) are being quickly adopted in clinics around the world. This advancement can greatly enhance the clinical care of patients with multiple sclerosis (MS) by providing formats that allow easier review of medical documents and more structured avenues to store relevant information. MS clinicians should be involved with implementing and updating EMRs at their institutions to ensure EMR formats that benefit MS clinics. EMRs also provide opportunities for research studies of MS to access detailed, longitudinal data of MS disease course that would otherwise be difficult to collect. PMID:25495075

  14. The intelligent use and clinical benefits of electronic medical records in multiple sclerosis.

    PubMed

    Davis, Mary F; Haines, Jonathan L

    2015-02-01

    Electronic medical records (EMRs) are being quickly adopted in clinics around the world. This advancement can greatly enhance the clinical care of patients with multiple sclerosis (MS) by providing formats that allow easier review of medical documents and more structured avenues to store relevant information. MS clinicians should be involved with implementing and updating EMRs at their institutions to ensure EMR formats that benefit MS clinics. EMRs also provide opportunities for research studies of MS to access detailed, longitudinal data of MS disease course that would otherwise be difficult to collect. PMID:25495075

  15. Urethral duplication in males: our experience in ten cases.

    PubMed

    Arena, Salvatore; Arena, Carmela; Scuderi, Maria Grazia; Sanges, Giuseppe; Arena, Francesco; Di Benedetto, Vincenzo

    2007-08-01

    Urethral duplication is a rare congenital anomaly, affecting mainly boys. Clinical presentation varies because of the different anatomical patterns of this abnormality. We report our experience in ten males affected by urethral duplication. We retrospectively reviewed the records of ten males affected by urethral duplication. Mild cases of distal type I duplications as well as "Y-type" duplication associated to anorectal malformation were excluded. Evaluation included voiding cystourethrography, retrograde urethrography, intravenous urography and urethrocystoscopy. Mean age at diagnosis was 46.7 +/- 32.3 months A blind ending duplicated urethra (type I) was present in three patients, two urethras originating from a common bladder neck (type II A2) in three, an "Y-type" duplication in three and a complete bladder with incomplete urethral duplication in one. Surgical management included excision of the duplicated urethra in four patients while a displacement of the ventral urethra (in "Y-type" duplication) in perineal-scrotal or scrotal position was performed in two patients as first stage of urethral reconstruction. Good cosmetical and functional results were achieved in all six treated boys while surgical management was not required in four. Urethral duplication is often associated with genito-urinary and gastro-intestinal abnormalities. Embryology is unclear and a lot of hypotheses have been proposed. We believe that the same embryological explanation cannot be applied to all subtypes of urethral duplication. Management must be evaluated for each case. The overall prognosis is good, in spite of the presence of other severe associate congenital anomalies. PMID:17576574

  16. Supervised Learning for Detection of Duplicates in Genomic Sequence Databases

    PubMed Central

    Zobel, Justin; Zhang, Xiuzhen; Verspoor, Karin

    2016-01-01

    Motivation First identified as an issue in 1996, duplication in biological databases introduces redundancy and even leads to inconsistency when contradictory information appears. The amount of data makes purely manual de-duplication impractical, and existing automatic systems cannot detect duplicates as precisely as can experts. Supervised learning has the potential to address such problems by building automatic systems that learn from expert curation to detect duplicates precisely and efficiently. While machine learning is a mature approach in other duplicate detection contexts, it has seen only preliminary application in genomic sequence databases. Results We developed and evaluated a supervised duplicate detection method based on an expert curated dataset of duplicates, containing over one million pairs across five organisms derived from genomic sequence databases. We selected 22 features to represent distinct attributes of the database records, and developed a binary model and a multi-class model. Both models achieve promising performance; under cross-validation, the binary model had over 90% accuracy in each of the five organisms, while the multi-class model maintains high accuracy and is more robust in generalisation. We performed an ablation study to quantify the impact of different sequence record features, finding that features derived from meta-data, sequence identity, and alignment quality impact performance most strongly. The study demonstrates machine learning can be an effective additional tool for de-duplication of genomic sequence databases. All Data are available as described in the supplementary material. PMID:27489953

  17. A Probabilistic Reasoning Method for Predicting the Progression of Clinical Findings from Electronic Medical Records

    PubMed Central

    Goodwin, Travis; Harabagiu, Sanda M.

    2015-01-01

    In this paper, we present a probabilistic reasoning method capable of generating predictions of the progression of clinical findings (CFs) reported in the narrative portion of electronic medical records. This method benefits from a probabilistic knowledge representation made possible by a graphical model. The knowledge encoded in the graphical model considers not only the CFs extracted from the clinical narratives, but also their chronological ordering (CO) made possible by a temporal inference technique described in this paper. Our experiments indicate that the predictions about the progression of CFs achieve high performance given the COs induced from patient records. PMID:26306238

  18. Automated semantic indexing of imaging reports to support retrieval of medical images in the multimedia electronic medical record.

    PubMed

    Lowe, H J; Antipov, I; Hersh, W; Smith, C A; Mailhot, M

    1999-12-01

    This paper describes preliminary work evaluating automated semantic indexing of radiology imaging reports to represent images stored in the Image Engine multimedia medical record system at the University of Pittsburgh Medical Center. The authors used the SAPHIRE indexing system to automatically identify important biomedical concepts within radiology reports and represent these concepts with terms from the 1998 edition of the U.S. National Library of Medicine's Unified Medical Language System (UMLS) Metathesaurus. This automated UMLS indexing was then compared with manual UMLS indexing of the same reports. Human indexing identified appropriate UMLS Metathesaurus descriptors for 81% of the important biomedical concepts contained in the report set. SAPHIRE automatically identified UMLS Metathesaurus descriptors for 64% of the important biomedical concepts contained in the report set. The overall conclusions of this pilot study were that the UMLS metathesaurus provided adequate coverage of the majority of the important concepts contained within the radiology report test set and that SAPHIRE could automatically identify and translate almost two thirds of these concepts into appropriate UMLS descriptors. Further work is required to improve both the recall and precision of this automated concept extraction process. PMID:10805018

  19. Automated semantic indexing of imaging reports to support retrieval of medical images in the multimedia electronic medical record.

    PubMed

    Lowe, H J; Antipov, I; Hersh, W; Smith, C A; Mailhot, M

    1999-12-01

    This paper describes preliminary work evaluating automated semantic indexing of radiology imaging reports to represent images stored in the Image Engine multimedia medical record system at the University of Pittsburgh Medical Center. The authors used the SAPHIRE indexing system to automatically identify important biomedical concepts within radiology reports and represent these concepts with terms from the 1998 edition of the U.S. National Library of Medicine's Unified Medical Language System (UMLS) Metathesaurus. This automated UMLS indexing was then compared with manual UMLS indexing of the same reports. Human indexing identified appropriate UMLS Metathesaurus descriptors for 81% of the important biomedical concepts contained in the report set. SAPHIRE automatically identified UMLS Metathesaurus descriptors for 64% of the important biomedical concepts contained in the report set. The overall conclusions of this pilot study were that the UMLS metathesaurus provided adequate coverage of the majority of the important concepts contained within the radiology report test set and that SAPHIRE could automatically identify and translate almost two thirds of these concepts into appropriate UMLS descriptors. Further work is required to improve both the recall and precision of this automated concept extraction process.

  20. Personal health records: a randomized trial of effects on elder medication safety

    PubMed Central

    Chrischilles, Elizabeth A; Hourcade, Juan Pablo; Doucette, William; Eichmann, David; Gryzlak, Brian; Lorentzen, Ryan; Wright, Kara; Letuchy, Elena; Mueller, Michael; Farris, Karen; Levy, Barcey

    2014-01-01

    Purpose To examine the impact of a personal health record (PHR) on medication-use safety among older adults. Background Online PHRs have potential as tools to manage health information. We know little about how to make PHRs accessible for older adults and what effects this will have. Methods A PHR was designed and pretested with older adults and tested in a 6-month randomized controlled trial. After completing mailed baseline questionnaires, eligible computer users aged 65 and over were randomized 3:1 to be given access to a PHR (n=802) or serve as a standard care control group (n=273). Follow-up questionnaires measured change from baseline medication use, medication reconciliation behaviors, and medication management problems. Results Older adults were interested in keeping track of their health and medication information. A majority (55.2%) logged into the PHR and used it, but only 16.1% used it frequently. At follow-up, those randomized to the PHR group were significantly less likely to use multiple non-steroidal anti-inflammatory drugs—the most common warning generated by the system (viewed by 23% of participants). Compared with low/non-users, high users reported significantly more changes in medication use and improved medication reconciliation behaviors, and recognized significantly more side effects, but there was no difference in use of inappropriate medications or adherence measures. Conclusions PHRs can engage older adults for better medication self-management; however, features that motivate continued use will be needed. Longer-term studies of continued users will be required to evaluate the impact of these changes in behavior on patient health outcomes. PMID:24326536

  1. Jackson Community Medical Record: a model for provider collaboration in a RHIO.

    PubMed

    Hayward, Mary K; Warren, Richard D; Sykes, Jonathan

    2007-01-01

    Foote Health System serves more than 247,000 individuals throughout six Michigan counties. In January 2005, FHS and Jackson Physicians Alliance, a 160-member physician contracting group, joined together to champion a community electronic health record by forming Jackson Community Medical Record LLC. JCMR selected and implemented of a fully integrated HIPAA-compliant EHR hosted on an application service provider. The shared database enables providers to leverage the work of each other. The community is already experiencing the benefits of the HER, including increased accuracy of medications, patient satisfaction, efficiency and reimbursement. The JCMR business model provides low entry costs and economies of scale. Software licenses and services are negotiated and held by JCMR. The interfaces between hospital systems and providers are maximized. JCMR is successfully bringing isolated islands of patient data together and serves a model for other communities. PMID:19195291

  2. Development of a clinical information tool for the electronic medical record: a case study*

    PubMed Central

    Epstein, Barbara A; Wessel, Charles B; Yarger, Frances; LaDue, John; Fiorillo, Anthony B

    2010-01-01

    Question: What is the process of developing a clinical information tool to be embedded in the electronic health record of a very large and diverse academic medical center? Setting: The development took place at the University of Pittsburgh Health Sciences Library System. Method: The clinical information tool developed is a search box with subject tabs to provide quick access to designated full-text information resources. Each subject tab offers a federated search of a different pool of resources. Search results are organized “on the fly” into meaningful categories using clustering technology and are directly accessible from the results page. Results: After more than a year of discussion and planning, a clinical information tool was embedded in the academic medical center's electronic health record. Conclusion: The library successfully developed a clinical information tool, called Clinical-e, for use at the point of care. Future development will refine the tool and evaluate its impact and effectiveness. PMID:20648256

  3. Image-based electronic patient records for secured collaborative medical applications.

    PubMed

    Zhang, Jianguo; Sun, Jianyong; Yang, Yuanyuan; Liang, Chenwen; Yao, Yihong; Cai, Weihua; Jin, Jin; Zhang, Guozhen; Sun, Kun

    2005-01-01

    We developed a Web-based system to interactively display image-based electronic patient records (EPR) for secured intranet and Internet collaborative medical applications. The system consists of four major components: EPR DICOM gateway (EPR-GW), Image-based EPR repository server (EPR-Server), Web Server and EPR DICOM viewer (EPR-Viewer). In the EPR-GW and EPR-Viewer, the security modules of Digital Signature and Authentication are integrated to perform the security processing on the EPR data with integrity and authenticity. The privacy of EPR in data communication and exchanging is provided by SSL/TLS-based secure communication. This presentation gave a new approach to create and manage image-based EPR from actual patient records, and also presented a way to use Web technology and DICOM standard to build an open architecture for collaborative medical applications. PMID:17282930

  4. The Evolution of Ambulatory Medical Record Systems in the U.S

    PubMed Central

    Kuhn, Ingeborg M.; Wiederhold, Gio

    1981-01-01

    This paper is an overview of the developments in Automated Ambulatory Medical Record Systems (AAMRS) from 1975 to the present. A summary of findings from a 1975 state-of-the-art review is presented with the current findings of a follow-up study of the AAMRS. The studies revealed that effective automated medical record systems have been developed for ambulatory care settings and that they are now in the process of being transfered to other sites or users, either privately or as a commercial product. Since 1975 there have been no significant advances in system design. However, progress has been substantial in terms of achieving production goals. Even though a variety of system are commercially available, there is a continuing need for research and development to improve the effectiveness of the systems in use today.

  5. The right of patients to have access to their medical records: the position in South African law.

    PubMed

    de Klerk, A

    1993-01-01

    In this article an investigation is undertaken into the right in South African law of a patient to have access to medical records concerning himself or herself, and the ownership of medical records in South African law is also discussed. It is argued that record accessibility by patients is to be favoured. The author is of the opinion that the South African legislature should consider legislation in this regard.

  6. Product-line administration: a framework for redefining medical record department services.

    PubMed

    Postal, S N

    1990-06-01

    Product-line administration is a viable approach for managing medical records services in an environment that demands high quantity and quality service levels. Product-line administration directs medical record department team members to look outside of the department and seek input from the customers it is intended to serve. The feedback received may be alarming at first, as the current state of products usually reveals a true lack of customer input. As the planning, defining, managing, and marketing phases are implemented, the road will not be easy and rewards will be slow to come. Product-line administration does not provide quick fixes, but it does provide long-term problem resolution as products are refined and new products developed to meet customer needs and expectations. In addition to better meeting the needs of the department's external customers, the department's internal customers' needs and expectations will be addressed. The participative management approach will help nurture each team member's creativity. The team members will have the opportunity to reach their full potential while reaping the rewards and benefits of providing products and services that meet the needs and expectations of all department customers. The future of the health care industry promises more changes as the country moves toward some form of prospective payment in the ambulatory setting. Reactive management and the constant struggle to catch up can no longer be accepted as a management approach. It is imperative that the medical record department be viewed as a business with product lines composed of quality products. The planning, defining, managing, and marketing components of product-line administration afford responsiveness to the current situation and the development of quality products that will ensure that medical record departments are prepared for the future.

  7. Patients' consent preferences for research uses of information in electronic medical records: interview and survey data

    PubMed Central

    Willison, Donald J; Keshavjee, Karim; Nair, Kalpana; Goldsmith, Charlie; Holbrook, Anne M

    2003-01-01

    Objectives To assess patients' preferred method of consent for the use of information from electronic medical records for research. Design Interviews and a structured survey of patients in practices with electronic medical records. Setting Family practices in southern Ontario, Canada. Participants 123 patients: 17 were interviewed and 106 completed a survey. Main outcome measures Patients' opinions and concerns on use of information from their medical records for research and their preferences for method of consent. Results Most interviewees were willing to allow the use of their information for research purposes, although the majority preferred that consent was sought first. The seeking of consent was considered an important element of respect for the individual. Most interviewees made little distinction between identifiable and anonymised data. Research sponsored by private insurance firms generated the greatest concern, and research sponsored by foundation the least. Sponsorship by drug companies evoked negative responses during interview and positive responses in the survey. Conclusions Patients are willing to allow information from their medical records to be used for research, but most prefer to be asked for consent either verbally or in writing. What is already known on this topicLegislation is being introduced worldwide to restrict the circumstances under which personal information may be used for secondary purposes without consentLittle empirical information exists about patients' concerns over privacy and preferences for consent for use of such information for researchWhat this study addsPatients are willing to allow personal information to be used for research purposes but want to be actively consulted firstPatients make little distinction between identifiable and non-identifiable informationMost patients prefer a time limit for their consent PMID:12586673

  8. A study of general practitioners’ perspectives on electronic medical records systems in NHSScotland

    PubMed Central

    2013-01-01

    Background Primary care doctors in NHSScotland have been using electronic medical records within their practices routinely for many years. The Scottish Health Executive eHealth strategy (2008-2011) has recently brought radical changes to the primary care computing landscape in Scotland: an information system (GPASS) which was provided free-of-charge by NHSScotland to a majority of GP practices has now been replaced by systems provided by two approved commercial providers. The transition to new electronic medical records had to be completed nationally across all health-boards by March 2012. Methods We carried out 25 in-depth semi-structured interviews with primary care doctors to elucidate GPs’ perspectives on their practice information systems and collect more general information on management processes in the patient surgical pathway in NHSScotland. We undertook a thematic analysis of interviewees’ responses, using Normalisation Process Theory as the underpinning conceptual framework. Results The majority of GPs’ interviewed considered that electronic medical records are an integral and essential element of their work during the consultation, playing a key role in facilitating integrated and continuity of care for patients and making clinical information more accessible. However, GPs expressed a number of reservations about various system functionalities – for example: in relation to usability, system navigation and information visualisation. Conclusion Our study highlights that while electronic information systems are perceived as having important benefits, there remains substantial scope to improve GPs’ interaction and overall satisfaction with these systems. Iterative user-centred improvements combined with additional training in the use of technology would promote an increased understanding, familiarity and command of the range of functionalities of electronic medical records among primary care doctors. PMID:23688255

  9. Rewriting abortion: deploying medical records in jurisdictional negotiation over a forbidden practice in Senegal

    PubMed Central

    Suh, Siri

    2014-01-01

    Boundary work refers to the strategies deployed by professionals in the arenas of the public, the law and the workplace to define and defend jurisdictional authority. Little attention has been directed to the role of documents in negotiating professional claims. While boundary work over induced abortion has been extensively documented, few studies have examined jurisdictional disputes over the treatment of abortion complications, or post-abortion care (PAC). This study explores how medical providers deploy medical records in boundary work over the treatment of complications of spontaneous and induced abortion in Senegal, where induced abortion is prohibited under any circumstance. Findings are based on an institutional ethnography of Senegal’s national PAC program over a period of 13 months between 2010 and 2011. Data collection methods included in-depth interviews with 36 health care professionals, observation of PAC services at three hospitals, a review of abortion records at each hospital, and a case review of illegal abortions prosecuted by the state. Findings show that health providers produce a particular account of the type of abortion treated through a series of practices such as the patient interview and the clinical exam. Providers obscure induced abortion in medical documents in three ways: the use of terminology that does not differentiate between induced and spontaneous abortion in PAC registers, the omission of data on the type of abortion altogether in PAC registers, and reporting the total number but not the type of abortions treated in hospital data transmitted to state health authorities. The obscuration of suspected induced abortion in the record permits providers to circumvent police inquiry at the hospital. PAC has been implemented in nearly 50 countries worldwide. This study demonstrates the need for additional research on how medical professionals negotiate conflicting medical and legal obligations in the daily practice of treating abortion

  10. Electronic medical record in the simulation hospital: does it improve accuracy in charting vital signs, intake, and output?

    PubMed

    Mountain, Carel; Redd, Roxanne; O'Leary-Kelly, Colleen; Giles, Kim

    2015-04-01

    Nursing care delivery has shifted in response to the introduction of electronic health records. Adequate education using computerized documentation heavily influences a nurse's ability to navigate and utilize electronic medical records. The risk for treatment error increases when a bedside nurse lacks the correct knowledge and skills regarding electronic medical record documentation. Prelicensure nursing education should introduce electronic medical record documentation and provide a method for feedback from instructors to ensure proper understanding and use of this technology. RN preceptors evaluated two groups of associate degree nursing students to determine if introduction of electronic medical record in the simulation hospital increased accuracy in documenting vital signs, intake, and output in the actual clinical setting. During simulation, the first group of students documented using traditional paper and pen; the second group used an academic electronic medical record. Preceptors evaluated each group during their clinical rotations at two local inpatient facilities. RN preceptors provided information by responding to a 10-question Likert scale survey regarding the use of student electronic medical record documentation during the 120-hour inpatient preceptor rotation. The implementation of the electronic medical record into the simulation hospital, although a complex undertaking, provided students a safe and supportive environment in which to practice using technology and receive feedback from faculty regarding accurate documentation.

  11. The Electronic Medical Records and Genomics (eMERGE) Network: past, present, and future

    PubMed Central

    Gottesman, Omri; Kuivaniemi, Helena; Tromp, Gerard; Faucett, W. Andrew; Li, Rongling; Manolio, Teri A.; Sanderson, Saskia C.; Kannry, Joseph; Zinberg, Randi; Basford, Melissa A.; Brilliant, Murray; Carey, David J.; Chisholm, Rex L.; Chute, Christopher G.; Connolly, John J.; Crosslin, David; Denny, Joshua C.; Gallego, Carlos J.; Haines, Jonathan L.; Hakonarson, Hakon; Harley, John; Jarvik, Gail P.; Kohane, Isaac; Kullo, Iftikhar J.; Larson, Eric B.; McCarty, Catherine; Ritchie, Marylyn D.; Roden, Dan M.; Smith, Maureen E.; Böttinger, Erwin P.; Williams, Marc S.

    2013-01-01

    The Electronic Medical Records and Genomics Network is a National Human Genome Research Institute–funded consortium engaged in the development of methods and best practices for using the electronic medical record as a tool for genomic research. Now in its sixth year and second funding cycle, and comprising nine research groups and a coordinating center, the network has played a major role in validating the concept that clinical data derived from electronic medical records can be used successfully for genomic research. Current work is advancing knowledge in multiple disciplines at the intersection of genomics and health-care informatics, particularly for electronic phenotyping, genome-wide association studies, genomic medicine implementation, and the ethical and regulatory issues associated with genomics research and returning results to study participants. Here, we describe the evolution, accomplishments, opportunities, and challenges of the network from its inception as a five-group consortium focused on genotype–phenotype associations for genomic discovery to its current form as a nine-group consortium pivoting toward the implementation of genomic medicine. Genet Med 15 10, 761–771. PMID:23743551

  12. New Advanced Technologies to Provide Decentralised and Secure Access to Medical Records: Case Studies in Oncology

    PubMed Central

    Quantin, Catherine; Coatrieux, Gouenou; Allaert, François André; Fassa, Maniane; Bourquard, Karima; Boire, Jean-Yves; de Vlieger, Paul; Maigne, Lydia; Breton, Vincent

    2009-01-01

    The main problem for health professionals and patients in accessing information is that this information is very often distributed over many medical records and locations. This problem is particularly acute in cancerology because patients may be treated for many years and undergo a variety of examinations. Recent advances in technology make it feasible to gain access to medical records anywhere and anytime, allowing the physician or the patient to gather information from an “ephemeral electronic patient record”. However, this easy access to data is accompanied by the requirement for improved security (confidentiality, traceability, integrity, ...) and this issue needs to be addressed. In this paper we propose and discuss a decentralised approach based on recent advances in information sharing and protection: Grid technologies and watermarking methodologies. The potential impact of these technologies for oncology is illustrated by the examples of two experimental cases: a cancer surveillance network and a radiotherapy treatment plan. It is expected that the proposed approach will constitute the basis of a future secure “google-like” access to medical records. PMID:19718446

  13. [Save or destroy? The importance of medical record for former patients and future patients].

    PubMed

    van Leeuwen, F E; Schornagel, J H

    2001-03-10

    In 1995, a new privacy law was introduced in the Netherlands. According to this law, medical records should be saved for 10 years, and then destroyed, unless keeping the records for a longer period follows reasonably from the duties of the treating physician (as is the case, for example, when treating patients with a chronic disease). There are serious concerns with regard to the future availability of medical record data for clinical research and patient care after 2005. Evaluation of the late effects of many medical treatments will no longer be possible in the Netherlands. Patient care, particularly genetic counselling, will be also seriously compromised. As a possible solution the profession might name diagnoses and treatments regarding for which, from the point of view of good care, it is necessary for files to be kept for longer than 10 years. For a uniform nationwide policy it would be better if all files, perhaps after sorting by diagnosis and treatment, should be obligatorily kept for much longer than 10 years, preferably for the duration of the life expectancy.

  14. Medical record information disclosure laws and policies among selected countries; a comparative study

    PubMed Central

    Yarmohammadian, Mohammad Hossein; Raeisi, Ahmad Reza; Tavakoli, Nahid; Nansa, Leila Ghaderi

    2010-01-01

    BACKGROUND: Hospitals have responsibility for responding to legitimate demands for release of health information while protecting the confidentiality of the patient health records. There have always been challenges concerning medical records confidentiality and their disclosure and release type in medical record departments. This study investigated and compared laws and policies of disclosure of health information in Iran and selected countries and tried to identify the differences and the similarities between them. METHODS: This is a descriptive and comparative study. The scope of study included related laws and policies of disclosure of health information in selected countries such as United States, Australia, England, Malaysia and Iran. Data were gathered from systematic internet search, library resources and communication with health information professionals. Data analysis was done using comparative tables and qualitative method. RESULTS: Study results showed that legislative institutions of each country have ordained laws and policies concerning disclosure and release of health information and in turn hospitals developed policies and procedures based on these laws. In Iran, however, there are few laws and policies concerning disclosure of health information in the form of formal letters and bylaws. There are no specific written policies and procedures for disclosure of health information in the hospitals. CONCLUSIONS: It is necessary to develop legitimate and appropriate laws and policies in different levels for information utilization by hospitals, medical universities and others. Meanwhile in all of the selected countries there are ordained limitations for release of health information for protecting health information in regard to patient rights. PMID:21526073

  15. The Electronic Medical Records and Genomics (eMERGE) Network: past, present, and future.

    PubMed

    Gottesman, Omri; Kuivaniemi, Helena; Tromp, Gerard; Faucett, W Andrew; Li, Rongling; Manolio, Teri A; Sanderson, Saskia C; Kannry, Joseph; Zinberg, Randi; Basford, Melissa A; Brilliant, Murray; Carey, David J; Chisholm, Rex L; Chute, Christopher G; Connolly, John J; Crosslin, David; Denny, Joshua C; Gallego, Carlos J; Haines, Jonathan L; Hakonarson, Hakon; Harley, John; Jarvik, Gail P; Kohane, Isaac; Kullo, Iftikhar J; Larson, Eric B; McCarty, Catherine; Ritchie, Marylyn D; Roden, Dan M; Smith, Maureen E; Böttinger, Erwin P; Williams, Marc S

    2013-10-01

    The Electronic Medical Records and Genomics Network is a National Human Genome Research Institute-funded consortium engaged in the development of methods and best practices for using the electronic medical record as a tool for genomic research. Now in its sixth year and second funding cycle, and comprising nine research groups and a coordinating center, the network has played a major role in validating the concept that clinical data derived from electronic medical records can be used successfully for genomic research. Current work is advancing knowledge in multiple disciplines at the intersection of genomics and health-care informatics, particularly for electronic phenotyping, genome-wide association studies, genomic medicine implementation, and the ethical and regulatory issues associated with genomics research and returning results to study participants. Here, we describe the evolution, accomplishments, opportunities, and challenges of the network from its inception as a five-group consortium focused on genotype-phenotype associations for genomic discovery to its current form as a nine-group consortium pivoting toward the implementation of genomic medicine.

  16. Natural Language Processing Based Instrument for Classification of Free Text Medical Records

    PubMed Central

    2016-01-01

    According to the Ministry of Labor, Health and Social Affairs of Georgia a new health management system has to be introduced in the nearest future. In this context arises the problem of structuring and classifying documents containing all the history of medical services provided. The present work introduces the instrument for classification of medical records based on the Georgian language. It is the first attempt of such classification of the Georgian language based medical records. On the whole 24.855 examination records have been studied. The documents were classified into three main groups (ultrasonography, endoscopy, and X-ray) and 13 subgroups using two well-known methods: Support Vector Machine (SVM) and K-Nearest Neighbor (KNN). The results obtained demonstrated that both machine learning methods performed successfully, with a little supremacy of SVM. In the process of classification a “shrink” method, based on features selection, was introduced and applied. At the first stage of classification the results of the “shrink” case were better; however, on the second stage of classification into subclasses 23% of all documents could not be linked to only one definite individual subclass (liver or binary system) due to common features characterizing these subclasses. The overall results of the study were successful. PMID:27668260

  17. Constraints on Biological Mechanism from Disease Comorbidity Using Electronic Medical Records and Database of Genetic Variants.

    PubMed

    Bagley, Steven C; Sirota, Marina; Chen, Richard; Butte, Atul J; Altman, Russ B

    2016-04-01

    Patterns of disease co-occurrence that deviate from statistical independence may represent important constraints on biological mechanism, which sometimes can be explained by shared genetics. In this work we study the relationship between disease co-occurrence and commonly shared genetic architecture of disease. Records of pairs of diseases were combined from two different electronic medical systems (Columbia, Stanford), and compared to a large database of published disease-associated genetic variants (VARIMED); data on 35 disorders were available across all three sources, which include medical records for over 1.2 million patients and variants from over 17,000 publications. Based on the sources in which they appeared, disease pairs were categorized as having predominant clinical, genetic, or both kinds of manifestations. Confounding effects of age on disease incidence were controlled for by only comparing diseases when they fall in the same cluster of similarly shaped incidence patterns. We find that disease pairs that are overrepresented in both electronic medical record systems and in VARIMED come from two main disease classes, autoimmune and neuropsychiatric. We furthermore identify specific genes that are shared within these disease groups. PMID:27115429

  18. Natural Language Processing Based Instrument for Classification of Free Text Medical Records

    PubMed Central

    2016-01-01

    According to the Ministry of Labor, Health and Social Affairs of Georgia a new health management system has to be introduced in the nearest future. In this context arises the problem of structuring and classifying documents containing all the history of medical services provided. The present work introduces the instrument for classification of medical records based on the Georgian language. It is the first attempt of such classification of the Georgian language based medical records. On the whole 24.855 examination records have been studied. The documents were classified into three main groups (ultrasonography, endoscopy, and X-ray) and 13 subgroups using two well-known methods: Support Vector Machine (SVM) and K-Nearest Neighbor (KNN). The results obtained demonstrated that both machine learning methods performed successfully, with a little supremacy of SVM. In the process of classification a “shrink” method, based on features selection, was introduced and applied. At the first stage of classification the results of the “shrink” case were better; however, on the second stage of classification into subclasses 23% of all documents could not be linked to only one definite individual subclass (liver or binary system) due to common features characterizing these subclasses. The overall results of the study were successful.

  19. The Electronic Medical Records and Genomics (eMERGE) Network: past, present, and future.

    PubMed

    Gottesman, Omri; Kuivaniemi, Helena; Tromp, Gerard; Faucett, W Andrew; Li, Rongling; Manolio, Teri A; Sanderson, Saskia C; Kannry, Joseph; Zinberg, Randi; Basford, Melissa A; Brilliant, Murray; Carey, David J; Chisholm, Rex L; Chute, Christopher G; Connolly, John J; Crosslin, David; Denny, Joshua C; Gallego, Carlos J; Haines, Jonathan L; Hakonarson, Hakon; Harley, John; Jarvik, Gail P; Kohane, Isaac; Kullo, Iftikhar J; Larson, Eric B; McCarty, Catherine; Ritchie, Marylyn D; Roden, Dan M; Smith, Maureen E; Böttinger, Erwin P; Williams, Marc S

    2013-10-01

    The Electronic Medical Records and Genomics Network is a National Human Genome Research Institute-funded consortium engaged in the development of methods and best practices for using the electronic medical record as a tool for genomic research. Now in its sixth year and second funding cycle, and comprising nine research groups and a coordinating center, the network has played a major role in validating the concept that clinical data derived from electronic medical records can be used successfully for genomic research. Current work is advancing knowledge in multiple disciplines at the intersection of genomics and health-care informatics, particularly for electronic phenotyping, genome-wide association studies, genomic medicine implementation, and the ethical and regulatory issues associated with genomics research and returning results to study participants. Here, we describe the evolution, accomplishments, opportunities, and challenges of the network from its inception as a five-group consortium focused on genotype-phenotype associations for genomic discovery to its current form as a nine-group consortium pivoting toward the implementation of genomic medicine. PMID:23743551

  20. A pragmatic method for electronic medical record-based observational studies: developing an electronic medical records retrieval system for clinical research

    PubMed Central

    Yamamoto, Keiichi; Sumi, Eriko; Yamazaki, Toru; Asai, Keita; Yamori, Masashi; Teramukai, Satoshi; Bessho, Kazuhisa; Yokode, Masayuki; Fukushima, Masanori

    2012-01-01

    Objective The use of electronic medical record (EMR) data is necessary to improve clinical research efficiency. However, it is not easy to identify patients who meet research eligibility criteria and collect the necessary information from EMRs because the data collection process must integrate various techniques, including the development of a data warehouse and translation of eligibility criteria into computable criteria. This research aimed to demonstrate an electronic medical records retrieval system (ERS) and an example of a hospital-based cohort study that identified both patients and exposure with an ERS. We also evaluated the feasibility and usefulness of the method. Design The system was developed and evaluated. Participants In total, 800 000 cases of clinical information stored in EMRs at our hospital were used. Primary and secondary outcome measures The feasibility and usefulness of the ERS, the method to convert text from eligible criteria to computable criteria, and a confirmation method to increase research data accuracy. Results To comprehensively and efficiently collect information from patients participating in clinical research, we developed an ERS. To create the ERS database, we designed a multidimensional data model optimised for patient identification. We also devised practical methods to translate narrative eligibility criteria into computable parameters. We applied the system to an actual hospital-based cohort study performed at our hospital and converted the test results into computable criteria. Based on this information, we identified eligible patients and extracted data necessary for confirmation by our investigators and for statistical analyses with our ERS. Conclusions We propose a pragmatic methodology to identify patients from EMRs who meet clinical research eligibility criteria. Our ERS allowed for the efficient collection of information on the eligibility of a given patient, reduced the labour required from the investigators and

  1. Evaluating the state of the art in coreference resolution for electronic medical records

    PubMed Central

    Bodnari, Andreea; Shen, Shuying; Forbush, Tyler; Pestian, John; South, Brett R

    2012-01-01

    Background The fifth i2b2/VA Workshop on Natural Language Processing Challenges for Clinical Records conducted a systematic review on resolution of noun phrase coreference in medical records. Informatics for Integrating Biology and the Bedside (i2b2) and the Veterans Affair (VA) Consortium for Healthcare Informatics Research (CHIR) partnered to organize the coreference challenge. They provided the research community with two corpora of medical records for the development and evaluation of the coreference resolution systems. These corpora contained various record types (ie, discharge summaries, pathology reports) from multiple institutions. Methods The coreference challenge provided the community with two annotated ground truth corpora and evaluated systems on coreference resolution in two ways: first, it evaluated systems for their ability to identify mentions of concepts and to link together those mentions. Second, it evaluated the ability of the systems to link together ground truth mentions that refer to the same entity. Twenty teams representing 29 organizations and nine countries participated in the coreference challenge. Results The teams' system submissions showed that machine-learning and rule-based approaches worked best when augmented with external knowledge sources and coreference clues extracted from document structure. The systems performed better in coreference resolution when provided with ground truth mentions. Overall, the systems struggled in solving coreference resolution for cases that required domain knowledge. PMID:22366294

  2. Computer Based Direct Digital Film Recording For Hard Copy Of Medical Images

    NASA Astrophysics Data System (ADS)

    Laskin, Bruce S.

    1984-06-01

    With the introduction of digital medical imaging modalities and picture archiving and communications systems (PACS) the necessary and desirable capabilities of a film recorder for hard-copy output will vary from the specifications of the current video-based recorder. Image data can be presented to the film recorder in a digital rather than analog video format. The resulting film image is no longer subject to degradation due to nonlinearities in the video portion of the recorder. Spatial resolution is also greatly enhanced (4096 x 4096 pixels). The inherent data processing capabilities of the digital film recorder allow a number of additional functions to be performed internally. Features of the system to be discussed include automatic calibration, automatic failure diagnosis, data compression and expansion, data error detection and correction, gamma and exposure compensation, alphanumeric and graphic frame identification, graphic image recording (EKG, EEG, EMG), color capability, data format conversion, multi-format multi-modality sequences, print spooling from multiple image sources and direct connection to a PACS network.

  3. FDA regulation of invasive neural recording electrodes: a daunting task for medical innovators.

    PubMed

    Welle, Cristin; Krauthamer, Victor

    2012-03-01

    The U.S. Food and Drug Administration (FDA) is charged with assuring the safety and effectiveness of medical devices. Before any medical device can be brought to market, it must comply with all federal regulations regarding FDA processes for clearance or approval. Navigating the FDA regulatory process may seem like a daunting task to the innovator of a novel medical device who has little experience with the FDA regulatory process or device commercialization. This review introduces the basics of the FDA regulatory premarket process, with a focus on issues relating to chronically implanted recording devices in the central or peripheral nervous system. Topics of device classification and regulatory pathways, the use of standards and guidance documents, and optimal time lines for interaction with the FDA are discussed. Additionally, this article summarizes the regulatory research on neural implant safety and reliability conducted by the FDA's Office of Science and Engineering Laboratories (OSEL) in collaboration with Defense Advanced Research Projects Agency (DARPA) Reliable Neural Technology (RE-NET) Program. For a more detailed explanation of the medical device regulatory process, please refer to several excellent reviews of the FDA's regulatory pathways for medical devices [1]-[4].

  4. From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age.

    PubMed

    Gillum, Richard F

    2013-10-01

    A major transition is underway in documentation of patient-related data in clinical settings with rapidly accelerating adoption of the electronic health record and electronic medical record. This article examines the history of the development of medical records in the West in order to suggest lessons applicable to the current transition. The first documented major transition in the evolution of the clinical medical record occurred in antiquity, with the development of written case history reports for didactic purposes. Benefiting from Classical and Hellenistic models earlier than physicians in the West, medieval Islamic physicians continued the development of case histories for didactic use. A forerunner of modern medical records first appeared in Paris and Berlin by the early 19th century. Development of the clinical record in America was pioneered in the 19th century in major teaching hospitals. However, a clinical medical record useful for direct patient care in hospital and ambulatory settings was not developed until the 20th century. Several lessons are drawn from the 4000-year history of the medical record that may help physicians improve patient care in the digital age. PMID:24054954

  5. Experiences sharing of implementing Template-based Electronic Medical Record System (TEMRS) in a Hong Kong medical organization.

    PubMed

    Ting, S L; Kwok, S K; Tsang, Albert H C; Lee, W B; Yee, K F

    2011-12-01

    This paper aims to investigate the efficacy and feasibility of Template-based Electronic Medical Record System (TEMRS) and factors for its successful implementation. A TEMRS was designed and implemented in one core clinic of a Hong Kong professional multi-disciplinary medical services provider with four core clinics located in different parts of Hong Kong. Eight doctors participated in the study. Surveys and interviews were conducted to acquire the users' feedback and satisfaction level. The design, development, and the factors related to the success of the implementation of TEMRS were analyzed. In the study period, 3,032 cases were collected. The most encountered diagnosis were upper respiratory tract infection (50.59%), gastroenteritis (10.19%), dermatitis (5.87%), dyspepsia (5.28%) and rhinitis (4.82%). The system gained an overall satisfaction by the users and the most satisfied areas were rapid retrieving the necessary information of patient (75%) and fasten the diagnostic selection (75%). TEMRS is an enabling system which can reduce the user resistance in new technology with its flexibility. The consideration of cost, security, human, technical, data migration and standardization issues are essential in the implementation of the TEMRS and further research should be conducted to expand the TEMRS's implementation in health care system.

  6. Maternal recall versus medical records of metabolic conditions from the prenatal period: A validation study

    PubMed Central

    Krakowiak, Paula; Walker, Cheryl K.; Tancredi, Daniel J.; Hertz-Picciotto, Irva

    2015-01-01

    Objectives To assess validity of maternally-reported diabetes and hypertensive disorders, and reliability of BMI measurements during periconception and pregnancy compared with medical records when mothers are interviewed 2-5 years after delivery. To investigate whether reporting accuracy differed by child's case status (autism, delays, typical development). Methods Participants were mothers of 2-5 year old children with and without neurodevelopmental disorders from the CHARGE (CHildhood Autism Risks from Genetics and the Environment) Study who had both prenatal/delivery records and telephone interviews. Sensitivity and specificity of self-report in telephone interview was assessed by comparison with medical records; agreement was evaluated by kappa statistics. Deviations in reported BMI were evaluated with Bland-Altman plots and concordance correlation coefficient (CCC). Results Mothers of children with neurodevelopmental disorders (autism or developmental delay) reported metabolic conditions slightly more accurately than control mothers. For diabetes, sensitivity ranged from 73% to 87% and specificity was ≥98% across groups. For hypertensive disorders, sensitivity ranged from 57% to 77% and specificity from 93% to 98%. Reliability of BMI was high (CCC=0.930); when grouped into BMI categories, a higher proportion of mothers of delayed children were correctly classified (κwt=0.93) compared with the autism group and controls (κwt=0.85 and κwt=0.84, respectively; P=0.05). Multiparity was associated with higher discrepancies in BMI and misreporting of hypertensive disorders. Conclusions For purposes of etiologic studies, self-reported diabetes and hypertensive disorders during periconception and pregnancy show high validity among mothers irrespective of child's case status. Recall of pre-pregnancy BMI is reliable compared with self-reported values in medical records. PMID:25656730

  7. RF-Medisys: a radio frequency identification-based electronic medical record system for improving medical information accessibility and services at point of care.

    PubMed

    Ting, Jacky S L; Tsang, Albert H C; Ip, Andrew W H; Ho, George T S

    2011-01-01

    This paper presents an innovative electronic medical records (EMR) system, RF-MediSys, which can perform medical information sharing and retrieval effectively and which is accessible via a 'smart' medical card. With such a system, medical diagnoses and treatment decisions can be significantly improved when compared with the conventional practice of using paper medical records systems. Furthermore, the entire healthcare delivery process, from registration to the dispensing or administration of medicines, can be visualised holistically to facilitate performance review. To examine the feasibility of implementing RF-MediSys and to determine its usefulness to users of the system, a survey was conducted within a multi-disciplinary medical service organisation that operates a network of medical clinics and paramedical service centres throughout Hong Kong Island, the Kowloon Peninsula and the New Territories. Questionnaires were distributed to 300 system users, including nurses, physicians and patients, to collect feedback on the operation and performance of RF-MediSys in comparison with conventional paper-based medical record systems. The response rate to the survey was 67%. Results showed a medium to high level of user satisfaction with the radiofrequency identification (RFID)-based EMR system. In particular, respondents provided high ratings on both 'user-friendliness' and 'system performance'. Findings of the survey highlight the potential of RF-MediSys as a tool to enhance quality of medical services and patient safety. PMID:21430306

  8. Evaluation of Electronic Medical Record (EMR) at Large Urban Primary Care Sexual Health Centre

    PubMed Central

    Huffam, Sarah; Cummings, Rosey; Chen, Marcus Y.; Sze, Jun K.; Fehler, Glenda; Bradshaw, Catriona S.; Schmidt, Tina; Berzins, Karen; Hocking, Jane S.

    2013-01-01

    Objective Despite substantial investment in Electronic Medical Record (EMR) systems there has been little research to evaluate them. Our aim was to evaluate changes in efficiency and quality of services after the introduction of a purpose built EMR system, and to assess its acceptability by the doctors, nurses and patients using it. Methods We compared a nine month period before and after the introduction of an EMR system in a large sexual health service, audited a sample of records in both periods and undertook anonymous surveys of both staff and patients. Results There were 9,752 doctor consultations (in 5,512 consulting hours) in the Paper Medical Record (PMR) period and 9,145 doctor consultations (in 5,176 consulting hours in the EMR period eligible for inclusion in the analysis. There were 5% more consultations per hour seen by doctors in the EMR period compared to the PMR period (rate ratio = 1.05; 95% confidence interval, 1.02, 1.08) after adjusting for type of consultation. The qualitative evaluation of 300 records for each period showed no difference in quality (P>0.17). A survey of clinicians demonstrated that doctors and nurses preferred the EMR system (P<0.01) and a patient survey in each period showed no difference in satisfaction of their care (97% for PMR, 95% for EMR, P = 0.61). Conclusion The introduction of an integrated EMR improved efficiency while maintaining the quality of the patient record. The EMR was popular with staff and was not associated with a decline in patient satisfaction in the clinical care provided. PMID:23593268

  9. Towards iconic language for patient records, drug monographs, guidelines and medical search engines.

    PubMed

    Lamy, Jean-Baptiste; Duclos, Catherine; Hamek, Saliha; Beuscart-Zéphir, Marie-Catherine; Kerdelhué, Gaetan; Darmoni, Stefan; Favre, Madeleine; Falcoff, Hector; Simon, Christian; Pereira, Suzanne; Serrot, Elisabeth; Mitouard, Thierry; Hardouin, Etienne; Kergosien, Yannick; Venot, Alain

    2010-01-01

    Practicing physicians have limited time for consulting medical knowledge and records. We have previously shown that using icons instead of text to present drug monographs may allow contraindications and adverse effects to be identified more rapidly and more accurately. These findings were based on the use of an iconic language designed for drug knowledge, providing icons for many medical concepts, including diseases, antecedents, drug classes and tests. In this paper, we describe a new project aimed at extending this iconic language, and exploring the possible applications of these icons in medicine. Based on evaluators' comments, focus groups of physicians and opinions of academic, industrial and associative partners, we propose iconic applications related to patient records, for example summarizing patient conditions, searching for specific clinical documents and helping to code structured data. Other applications involve the presentation of clinical practice guidelines and improving the interface of medical search engines. These new applications could use the same iconic language that was designed for drug knowledge, with a few additional items that respect the logic of the language.

  10. Should medical students track former patients in the electronic health record? An emerging ethical conflict.

    PubMed

    Brisson, Gregory E; Neely, Kathy Johnson; Tyler, Patrick D; Barnard, Cynthia

    2015-08-01

    Medical students are increasingly using electronic health records (EHRs) in clerkships, and medical educators should seek opportunities to use this new technology to improve training. One such opportunity is the ability to "track" former patients in the EHR, defined as following up on patients in the EHR for educational purposes for a defined period of time after they have left one's direct care. This activity offers great promise in clinical training by enabling students to audit their diagnostic impressions and follow the clinical history of illness in a manner not possible in the era of paper charting. However, tracking raises important questions about the ethical use of protected health information, including concerns about compromising patient autonomy, resulting in a conflict between medical education and patient privacy. The authors offer critical analysis of arguments on both sides and discuss strategies to balance the ethical conflict by optimizing outcomes and mitigating harms. They observe that tracking improves training, thus offering long-lasting benefits to society, and is supported by the principle of distributive justice. They conclude that students should be permitted to track for educational purposes, but only with defined limits to safeguard patient autonomy, including obtaining permission from patients, having legitimate educational intent, and self-restricting review of records to those essential for training. Lastly, the authors observe that this conflict will become increasingly important with completion of the planned Nationwide Health Information Network and emphasize the need for national guidelines on tracking patients in an ethically appropriate manner.

  11. The VA Hypertension Primary Care Longitudinal Cohort: Electronic medical records in the post-genomic era

    PubMed Central

    Salem, Rany M.; Pandey, Braj; Richard, Erin; Fung, Maple M.; Garcia, Erin P.; Brophy, Victoria H.; Schork, Nicholas J.; O'Connor, Daniel T.; Bhatnagar, Vibha

    2011-01-01

    The Veterans Affairs Hypertension Primary Care Longitudinal Cohort (VAHC) was initiated in 2003 as a pilot study designed to link the VA electronic medical record system with individual genetic data. Between June 2003 and December 2004, 1,527 hypertensive participants were recruited. Protected health information (PHI) was extracted from the regional VA data warehouse. Differences between the clinic and mail recruits suggested that clinic recruitment resulted in an over-sampling of African Americans. A review of medical records in a random sample of study participants confirmed that the data warehouse accurately captured most selected diagnoses. Genomic DNA was acquired non-invasively from buccal cells in mouthwash; ~ 96.5 per cent of samples contained DNA suitable for genotyping, with an average DNA yield of 5.02 ± 0.12 micrograms, enough for several thousand genotypes. The coupling of detailed medical databases with genetic information has the potential to facilitate the genetic study of hypertension and other complex diseases. PMID:21216807

  12. Retroperitoneal enteric duplication cyst.

    PubMed

    Lo, Yu-Shing; Wang, Jyh-Seng; Yu, Chia-Cheng; Chou, Chung-Ping; Chen, Chia-Jung; Lin, Shong-Ling; Lee, Mang-Gang; Kuo, Yau-Chang; Tseng, Hui-Hwa

    2004-09-01

    Enteric duplication cysts (EDCs) can occur in any portion of the alimentary tract, but are most commonly associated with the small bowel and esophagus. Retroperitoneal location is really unusual. This 19-year-old female was in excellent health, but a week's abdominal pain made her search for a doctor's help. After the detailed examination, surgical intervention was performed under the impression of cystic tumor of the retroperitoneum. A retroperitoneal cystic tumor, 13.0 x 8.0 x 3.5 cm in size, without any communication with the alimentary tract was noted during the operation. Finally, EDC was diagnosed after the pathologic examination of this resected cystic lesion. To our knowledge, there have been only 6 reported cases of EDC of the retroperitoneum in the English literature. This report concerns the seventh case of retroperitoneal EDC, in an adolescent, with different clinical presentation and histopathologic findings from the previous ones.

  13. Web tools for effective retrieval, visualization, and evaluation of cardiology medical images and records

    NASA Astrophysics Data System (ADS)

    Masseroli, Marco; Pinciroli, Francesco

    2000-12-01

    To provide easy retrieval, integration and evaluation of multimodal cardiology images and data in a web browser environment, distributed application technologies and java programming were used to implement a client-server architecture based on software agents. The server side manages secure connections and queries to heterogeneous remote databases and file systems containing patient personal and clinical data. The client side is a Java applet running in a web browser and providing a friendly medical user interface to perform queries on patient and medical test dat and integrate and visualize properly the various query results. A set of tools based on Java Advanced Imaging API enables to process and analyze the retrieved cardiology images, and quantify their features in different regions of interest. The platform-independence Java technology makes the developed prototype easy to be managed in a centralized form and provided in each site where an intranet or internet connection can be located. Giving the healthcare providers effective tools for querying, visualizing and evaluating comprehensively cardiology medical images and records in all locations where they can need them- i.e. emergency, operating theaters, ward, or even outpatient clinics- the developed prototype represents an important aid in providing more efficient diagnoses and medical treatments.

  14. Detecting earlier indicators of homelessness in the free text of medical records.

    PubMed

    Redd, Andrew; Carter, Marjorie; Divita, Guy; Shen, Shuying; Palmer, Miland; Samore, Matthew; Gundlapalli, Adi V

    2014-01-01

    Early warning indicators to identify US Veterans at risk of homelessness are currently only inferred from administrative data. References to indicators of risk or instances of homelessness in the free text of medical notes written by Department of Veterans Affairs (VA) providers may precede formal identification of Veterans as being homeless. This represents a potentially untapped resource for early identification. Using natural language processing (NLP), we investigated the idea that concepts related to homelessness written in the free text of the medical record precede the identification of homelessness by administrative data. We found that homeless Veterans were much higher utilizers of VA resources producing approximately 12 times as many documents as non-homeless Veterans. NLP detected mentions of either direct or indirect evidence of homelessness in a significant portion of Veterans earlier than structured data.

  15. Risk factor detection for heart disease by applying text analytics in electronic medical records.

    PubMed

    Torii, Manabu; Fan, Jung-Wei; Yang, Wei-Li; Lee, Theodore; Wiley, Matthew T; Zisook, Daniel S; Huang, Yang

    2015-12-01

    In the United States, about 600,000 people die of heart disease every year. The annual cost of care services, medications, and lost productivity reportedly exceeds 108.9 billion dollars. Effective disease risk assessment is critical to prevention, care, and treatment planning. Recent advancements in text analytics have opened up new possibilities of using the rich information in electronic medical records (EMRs) to identify relevant risk factors. The 2014 i2b2/UTHealth Challenge brought together researchers and practitioners of clinical natural language processing (NLP) to tackle the identification of heart disease risk factors reported in EMRs. We participated in this track and developed an NLP system by leveraging existing tools and resources, both public and proprietary. Our system was a hybrid of several machine-learning and rule-based components. The system achieved an overall F1 score of 0.9185, with a recall of 0.9409 and a precision of 0.8972.

  16. A Patient-Held Medical Record Integrating Depression Care into Diabetes Care

    PubMed Central

    Satoh-Asahara, Noriko; Ito, Hiroto; Akashi, Tomoyuki; Yamakage, Hajime; Kotani, Kazuhiko; Nagata, Daisuke; Nakagome, Kazuyuki; Noda, Mitsuhiko

    2016-01-01

    PURPOSE Depression is frequently observed in people with diabetes. The purpose of this study is to develop a tool for individuals with diabetes and depression to communicate their comorbid conditions to health-care providers. METHOD We searched the Internet to review patient-held medical records (PHRs) of patients with diabetes and examine current levels of integration of diabetes and depression care in Japan. RESULTS Eight sets of PHRs were found for people with diabetes. All PHRs included clinical follow-up of diabetes and multidisciplinary clinical pathways for diabetes care. No PHRs included depression monitoring and/or treatment. In terms of an integrated PHR for a patient comorbid with diabetes and depression, necessary components include hopes/preferences, educational information on diabetes complications and treatment, medical history, stress and coping, resources, and monitoring diabetes and depression. CONCLUSION A new PHR may be suitable for comorbid patients with diabetes and depression. PMID:27478395

  17. Rapid deployment of electronic medical records for ARV rollout in rural Rwanda.

    PubMed

    Allen, Christian; Manyika, Patrick; Jazayeri, Darius; Rich, Michael; Lesh, Neal; Fraser, Hamish

    2006-01-01

    While most people with AIDS do not yet have access to anti-retroviral drugs (ARVs), large ARV treatment programs are being rolled out in many areas in Sub-Saharan Africa. ARV programs have substantial data management needs, which electronic medical record systems (EMRs) are helping to address. While most sophisticated EMRs in low-income regions are in large cities, where infrastructure and staffing needs are more easily met, Partners In Health (PIH) has pioneered web-based EMRs for HIV and TB treatment in rural areas. The HIV-EMR, developed in Haiti [1], was de-ployed in two Rwandan health districts starting in Au-gust 2005. The addition of new features and adaptation to local needs is happening concurrently with the rapid scale-up and evolution of the medical program itself.

  18. Health care professionals’ pain narratives in hospitalized children’s medical records. Part 1: Pain descriptors

    PubMed Central

    Rashotte, Judy; Coburn, Geraldine; Harrison, Denise; Stevens, Bonnie J; Yamada, Janet; Abbott, Laura K

    2013-01-01

    BACKGROUND: Although documentation of children’s pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children. OBJECTIVES: To describe health care professionals’ use of written language related to the quality and quantity of pain experienced by hospitalized children. METHODS: Free-text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used. RESULTS: Pain narratives were documented a total of 5390 times in 1518 of the 3822 children’s medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (eg, vocal, motor, facial and activities cues), affective and physiological cues, and children’s descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers. CONCLUSIONS: The richness and complexity of vocabulary used by clinicians to document children’s pain lend support to the concept that the word ‘pain’ is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children’s pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals. PMID:24093122

  19. DICOM image integration into an electronic medical record using thin viewing clients

    NASA Astrophysics Data System (ADS)

    Stewart, Brent K.; Langer, Steven G.; Taira, Ricky K.

    1998-07-01

    Purpose -- To integrate radiological DICOM images into our currently existing web-browsable Electronic Medical Record (MINDscape). Over the last five years the University of Washington has created a clinical data repository combining in a distributed relational database information from multiple departmental databases (MIND). A text-based view of this data called the Mini Medical Record (MMR) has been available for three years. MINDscape, unlike the text based MMR, provides a platform independent, web browser view of the MIND dataset that can easily be linked to other information resources on the network. We have now added the integration of radiological images into MINDscape through a DICOM webserver. Methods/New Work -- we have integrated a commercial webserver that acts as a DICOM Storage Class Provider to our, computed radiography (CR), computed tomography (CT), digital fluoroscopy (DF), magnetic resonance (MR) and ultrasound (US) scanning devices. These images can be accessed through CGI queries or by linking the image server database using ODBC or SQL gateways. This allows the use of dynamic HTML links to the images on the DICOM webserver from MINDscape, so that the radiology reports already resident in the MIND repository can be married with the associated images through the unique examination accession number generated by our Radiology Information System (RIS). The web browser plug-in used provides a wavelet decompression engine (up to 16-bits per pixel) and performs the following image manipulation functions: window/level, flip, invert, sort, rotate, zoom, cine-loop and save as JPEG. Results -- Radiological DICOM image sets (CR, CT, MR and US) are displayed with associated exam reports for referring physician and clinicians anywhere within the widespread academic medical center on PCs, Macs, X-terminals and Unix computers. This system is also being used for home teleradiology application. Conclusion -- Radiological DICOM images can be made available

  20. Impact of a New Medical Record System for Emergency Departments Designed to Accelerate Clinical Documentation

    PubMed Central

    Inokuchi, Ryota; Sato, Hajime; Iwagami, Masao; Komaru, Yohei; Iwai, Satoshi; Gunshin, Masataka; Nakamura, Kensuke; Shinohara, Kazuaki; Kitsuta, Yoichi; Nakajima, Susumu; Yahagi, Naoki

    2015-01-01

    Abstract Recording information in emergency departments (EDs) constitutes a major obstacle to efficient treatment. A new electronic medical records (EMR) system focusing on clinical documentation was developed to accelerate patient flow. The aim of this study was to examine the impact of a new EMR system on ED length of stay and physician satisfaction. We integrated a new EMR system at a hospital already using a standard system. A crossover design was adopted whereby residents were randomized into 2 groups. Group A used the existing EMR system first, followed by the newly developed system, for 2 weeks each. Group B followed the opposite sequence. The time required to provide overall medical care, length of stay in ED, and degree of physician satisfaction were compared between the 2 EMR systems. The study involved 6 residents and 526 patients (277 assessed using the standard system and 249 assessed with the new system). Mean time for clinical documentation decreased from 133.7 ± 5.1 minutes to 107.5 ± 5.4 minutes with the new EMR system (P < 0.001). The time for overall medical care was significantly reduced in all patient groups except triage level 5 (nonurgent). The new EMR system significantly reduced the length of stay in ED for triage level 2 (emergency) patients (145.4 ± 13.6 minutes vs 184.3 ± 13.6 minutes for standard system; P = 0.047). As for the degree of physician satisfaction, there was a high degree of satisfaction in terms of the physical findings support system and the ability to capture images and enter negative findings. The new EMR system shortened the time for overall medical care and was associated with a high degree of resident satisfaction. PMID:26131837

  1. The politics of healthcare informatics: knowledge management using an electronic medical record system.

    PubMed

    Bar-Lev, Shirly

    2015-03-01

    The design and implementation of an electronic medical record system pose significant epistemological and practical complexities. Despite optimistic assessments of their potential contribution to the quality of care, their implementation has been problematic, and their actual employment in various clinical settings remains controversial. Little is known about how their use actually mediates knowing. Employing a variety of qualitative research methods, this article attempts an answer by illustrating how omitting, editing and excessive reporting were employed as part of nurses' and physicians' political efforts to shape knowledge production and knowledge sharing in a technologically mediated healthcare setting.

  2. Risk mitigation of shared electronic records system in campus institutions: medical social work practice in singapore.

    PubMed

    Ow Yong, Lai Meng; Tan, Amanda Wei Li; Loo, Cecilia Lay Keng; Lim, Esther Li Ping

    2014-10-01

    In 2013, the Singapore General Hospital (SGH) Campus initiated a shared electronic system where patient records and documentations were standardized and shared across institutions within the Campus. The project was initiated to enhance quality of health care, improve accessibility, and ensure integrated (as opposed to fragmented) care for best outcomes in our patients. In mitigating the risks of ICT, it was found that familiarity with guiding ethical principles, and ensuring adherence to regulatory and technical competencies in medical social work were important. The need to negotiate and maneuver in a large environment within the Campus to ensure proactive integrative process helped. PMID:25321932

  3. Clinical challenges associated with incorporation of nonradiology images into the electronic medical record

    NASA Astrophysics Data System (ADS)

    Siegel, Eliot L.; Reiner, Bruce I.

    2001-08-01

    To date, the majority of Picture Archival and Communication Systems (PACS) have been utilized only for capture, storage, and display of radiology and in some cases, nuclear medicine images. Medical images for other subspecialty areas are currently stored in local, independent systems, which typically are not accessible throughout the healthcare enterprise and do not communicate with other hospital information or image management systems. It is likely that during the next few years, healthcare centers will expand PAC system capability to incorporate these multimedia data or alternatively, hospital-wide electronic patient record systems will be able to provide this function.

  4. Risk mitigation of shared electronic records system in campus institutions: medical social work practice in singapore.

    PubMed

    Ow Yong, Lai Meng; Tan, Amanda Wei Li; Loo, Cecilia Lay Keng; Lim, Esther Li Ping

    2014-10-01

    In 2013, the Singapore General Hospital (SGH) Campus initiated a shared electronic system where patient records and documentations were standardized and shared across institutions within the Campus. The project was initiated to enhance quality of health care, improve accessibility, and ensure integrated (as opposed to fragmented) care for best outcomes in our patients. In mitigating the risks of ICT, it was found that familiarity with guiding ethical principles, and ensuring adherence to regulatory and technical competencies in medical social work were important. The need to negotiate and maneuver in a large environment within the Campus to ensure proactive integrative process helped.

  5. The politics of healthcare informatics: knowledge management using an electronic medical record system.

    PubMed

    Bar-Lev, Shirly

    2015-03-01

    The design and implementation of an electronic medical record system pose significant epistemological and practical complexities. Despite optimistic assessments of their potential contribution to the quality of care, their implementation has been problematic, and their actual employment in various clinical settings remains controversial. Little is known about how their use actually mediates knowing. Employing a variety of qualitative research methods, this article attempts an answer by illustrating how omitting, editing and excessive reporting were employed as part of nurses' and physicians' political efforts to shape knowledge production and knowledge sharing in a technologically mediated healthcare setting. PMID:25581280

  6. Nursing Students' Satisfaction with Mobile Academic Electronic Medical Records for Undergraduate Clinical Practicum.

    PubMed

    Choi, Mona; Park, Joon Ho; Lee, Hyeong Suk

    2016-01-01

    The purpose of study was to evaluate satisfaction with and usability of mobile academic electronic medical records (AEMR) for undergraduate nursing students' clinical practicum. After an AEMR application on mobile devices was applied to the experimental group while a PC-based EMR system was used for the control group as usual in the fall semester, 2014. Two items of practicum satisfaction such as preparation of lab test and understanding of the results, and nursing intervention and documentation were significantly higher in the experiment group. The findings of usability survey showed that students in the experiment group consider the use of mobile AEMR in their job would increase their productivity. PMID:27332454

  7. Task and error analysis balancing benefits over business of electronic medical records.

    PubMed

    Carstens, Deborah Sater; Rodriguez, Walter; Wood, Michael B

    2014-01-01

    Task and error analysis research was performed to identify: a) the process for healthcare organisations in managing healthcare for patients with mental illness or substance abuse; b) how the process can be enhanced and; c) if electronic medical records (EMRs) have a role in this process from a business and safety perspective. The research question is if EMRs have a role in enhancing the healthcare for patients with mental illness or substance abuse. A discussion on the business of EMRs is addressed to understand the balancing act between the safety and business aspects of an EMR.

  8. Replacing personally-identifying information in medical records, the Scrub system.

    PubMed Central

    Sweeney, L.

    1996-01-01

    We define a new approach to locating and replacing personally-identifying information in medical records that extends beyond straight search-and-replace procedures, and we provide techniques for minimizing risk to patient confidentiality. The straightforward approach of global search and replace properly located no more than 30-60% of all personally-identifying information that appeared explicitly in our sample database. On the other hand, our Scrub system found 99-100% of these references. Scrub uses detection algorithms that employ templates and specialized knowledge of what constitutes a name, address, phone number and so forth. PMID:8947683

  9. Development and Preliminary Evaluation of a Prototype of a Learning Electronic Medical Record System

    PubMed Central

    King, Andrew J.; Cooper, Gregory F.; Hochheiser, Harry; Clermont, Gilles; Visweswaran, Shyam

    2015-01-01

    Electronic medical records (EMRs) are capturing increasing amounts of data per patient. For clinicians to efficiently and accurately understand a patient’s clinical state, better ways are needed to determine when and how to display EMR data. We built a prototype system that records how physicians view EMR data, which we used to train models that predict which EMR data will be relevant in a given patient. We call this approach a Learning EMR (LEMR). A physician used the prototype to review 59 intensive care unit (ICU) patient cases. We used the data-access patterns from these cases to train logistic regression models that, when evaluated, had AUROC values as high as 0.92 and that averaged 0.73, supporting that the approach is promising. A preliminary usability study identified advantages of the system and a few concerns about implementation. Overall, 3 of 4 ICU physicians were enthusiastic about features of the prototype. PMID:26958296

  10. Development of a character, line and point display system. [for medical records

    NASA Technical Reports Server (NTRS)

    Owen, E. W.

    1977-01-01

    A compact graphics terminal for use as the input to a computerized medical records system is described. The principal mode of communication between the terminal and the records system is by checklists and menu selection. However, the terminal accepts short, handwritten messages as well as conventional alphanumeric input. The terminal consists of an electronic tablet, a display, a microcomputer controller, a character generator, and a refresh memory for the display. An Intel SBC 80/10 microcomputer controls the flow of information and a 16 kilobyte memory stores the point-by-point array of information to be displayed. A specially designed interface continuously generates the raster display without the intervention of the microcomputer.

  11. Beyond information retrieval and electronic health record use: competencies in clinical informatics for medical education.

    PubMed

    Hersh, William R; Gorman, Paul N; Biagioli, Frances E; Mohan, Vishnu; Gold, Jeffrey A; Mejicano, George C

    2014-01-01

    Physicians in the 21st century will increasingly interact in diverse ways with information systems, requiring competence in many aspects of clinical informatics. In recent years, many medical school curricula have added content in information retrieval (search) and basic use of the electronic health record. However, this omits the growing number of other ways that physicians are interacting with information that includes activities such as clinical decision support, quality measurement and improvement, personal health records, telemedicine, and personalized medicine. We describe a process whereby six faculty members representing different perspectives came together to define competencies in clinical informatics for a curriculum transformation process occurring at Oregon Health & Science University. From the broad competencies, we also developed specific learning objectives and milestones, an implementation schedule, and mapping to general competency domains. We present our work to encourage debate and refinement as well as facilitate evaluation in this area.

  12. Pilot study on identification of incidents in healthcare transitions and concordance between medical records and patient interview data

    PubMed Central

    van Melle, Marije A; Erkelens, Daphne C A; van Stel, Henk F; de Wit, Niek J; Zwart, Dorien L M

    2016-01-01

    Objective To investigate whether transitional incidents can be identified from the medical records of the general practitioners and the hospital and to assess the concordance of transitional incidents between medical records and patient interviews. Design A pilot study. Setting The study was conducted in 2 regions in the Netherlands: a rural and an urban region. Participants A purposeful sample of patients who experienced a transitional incident or are at high risk of experiencing transitional incidents. Main outcome measures Transitional incidents were identified from both the interviews with patients and medical records and concordance was assessed. We also classified the transitional incidents according to type, severity, estimated cause and preventability. Results We identified 28 transitional incidents within 78 transitions of which 3 could not be found in the medical records and another 5 could have been missed without the patient as information source. To summarise, 8 (29%) incidents could have been missed using solely medical records, and 7 (25%) using the patients’ information exclusively. Concordance in transitional incidents between patient interviews and medical records was 64% (18/28). The majority of the transitional incidents were unsafe situations; however, 43% (12/28) of the incidents reached the patient and 18% (5/28) caused temporary patient harm. Over half of the incidents were potentially preventable. Conclusions This pilot study suggests that the majority of transitional incidents can be identified from medical records of the general practitioner and hospital. With this information, we aim to develop a measurement tool for transitional incidents in the medical record of general practitioner and hospital. PMID:27543588

  13. Identifying patients with medically unexplained physical symptoms in electronic medical records in primary care: a validation study

    PubMed Central

    2014-01-01

    Background When medically unexplained physical symptoms (MUPS) become persistent, it may have major implications for the patient, the general practitioner (GP) and for society. Early identification of patients with MUPS in electronic medical records (EMRs) might contribute to prevention of persistent MUPS by creating awareness among GPs and providing an opportunity to start stepped care management. However, procedures for identification of patients with MUPS in EMRs are not well established yet. In this validation study we explore the test characteristics of an EMR screening method to identify patients with MUPS. Methods The EMR screening method consists of three steps. First, all patients ≥18 years were included when they had five or more contacts in the last 12 months. Second, patients with known chronic conditions were excluded. Finally, patients were included with a MUPS syndrome or when they had three or more complaints suggestive for MUPS. We compared the results of the EMR screening method with scores on the Patient Health Questionnaire-15 (PHQ-15), which we used as reference test. We calculated test characteristics for various cut-off points. Results From the 1223 patients in our dataset who completed the PHQ-15, 609 (49/8%) scored ≥5 on the PHQ-15. The EMR screening method detected 131/1223 (10.7%) as patients with MUPS. Of those, 102 (77.9%) scored ≥5 on the PHQ-15 and 53 (40.5%) scored ≥10. When compared with the PHQ-15 cut-off point ≥10, sensitivity and specificity were 0.30 and 0.93 and positive and negative predictive values were 0.40 and 0.89, respectively. Conclusions The EMR screening method to identify patients with MUPS has a high specificity. However, many potential MUPS patients will be missed. Before using this method as a screening instrument for selecting patients who might benefit from structured care, its sensitivity needs to be improved while maintaining its specificity. PMID:24903850

  14. Implementing and Integrating a Clinically Driven Electronic Medical Record for Radiation Oncology in a Large Medical Enterprise

    PubMed Central

    Kirkpatrick, John P.; Light, Kim L.; Walker, Robyn M.; Georgas, Debra L.; Antoine, Phillip A.; Clough, Robert W.; Cozart, Heidi B.; Yin, Fang-Fang; Yoo, Sua; Willett, Christopher G.

    2013-01-01

    Purpose/Objective: While our department is heavily invested in computer-based treatment planning, we historically relied on paper-based charts for management of Radiation Oncology patients. In early 2009, we initiated the process of conversion to an electronic medical record (EMR) eliminating the need for paper charts. Key goals included the ability to readily access information wherever and whenever needed, without compromising safety, treatment quality, confidentiality, or productivity. Methodology: In February, 2009, we formed a multi-disciplinary team of Radiation Oncology physicians, nurses, therapists, administrators, physicists/dosimetrists, and information technology (IT) specialists, along with staff from the Duke Health System IT department. The team identified all existing processes and associated information/reports, established the framework for the EMR system and generated, tested and implemented specific EMR processes. Results: Two broad classes of information were identified: information which must be readily accessed by anyone in the health system versus that used solely within the Radiation Oncology department. Examples of the former are consultation reports, weekly treatment check notes, and treatment summaries; the latter includes treatment plans, daily therapy records, and quality assurance reports. To manage the former, we utilized the enterprise-wide system, which required an intensive effort to design and implement procedures to export information from Radiation Oncology into that system. To manage “Radiation Oncology” data, we used our existing system (ARIA, Varian Medical Systems.) The ability to access both systems simultaneously from a single workstation (WS) was essential, requiring new WS and modified software. As of January, 2010, all new treatments were managed solely with an EMR. We find that an EMR makes information more widely accessible and does not compromise patient safety, treatment quality, or confidentiality. However

  15. Authorized Duplication: A Timely Solution.

    ERIC Educational Resources Information Center

    Curatilo, Joe

    1997-01-01

    Asks how a music teacher can supply enough sheet music to ensure resources for every student while meeting restrictions of slender budgets and copyright laws. Explores the concept of authorized duplication, similar to software licensing, as a solution. Provides sources of music with authorized duplication agreements. (DSK)

  16. Healthcare and Guidelines: A Population-Based Survey of Recorded Medical Problems and Health Surveillance for People with Down syndrome

    ERIC Educational Resources Information Center

    Maatta, Tuomo; Maatta, Joonas; Tervo-Maatta, Tuula; Taanila, Anja; Kaski, Markus; Iivanainen, Matti

    2011-01-01

    Background: Medical problems are described in a population of persons with Down syndrome. Health surveillance is compared to the recommendations of national guidelines. Method: Case records from the specialised and primary healthcare and disability services were analysed. Results: A wide spectrum of age-specific medical and surgical problems was…

  17. Integrating an enterprise image distribution system into an existing electronic medical record system

    NASA Astrophysics Data System (ADS)

    Witt, Robert M.; Morrow, Robert

    2003-05-01

    The enterprise distribution of radiology images should be integrated into the same application that physicians obtain other clinical information about their patients. Over the past year the Roudebush Veterans Affairs Medical Center has provided enterprise access to radiology images after integrating a commercial web-based image distribution system (Stentor, Brisbane, CA) with the Department of Veterans Affairs internally developed Computerized Patient Record System (CPRS). The application, CPRS, serves as the foundation for the VHA to implement an electronic medical record (EMR). We developed the necessary program communications between the CPRS application and the image distribution application to link the request for a report to a request for the corresponding images. When a physician selects a given radiology report in CPRS the text of the report displays in CPRS and the image application loads the corresponding image study. We found that the requests for film jackets decreased over fifty percent six months after full implementation of the enterprise image distribution system. We have found the integration of the image access and display application into an existing patient information system to be very successful.

  18. Efficient Queries of Stand-off Annotations for Natural Language Processing on Electronic Medical Records.

    PubMed

    Luo, Yuan; Szolovits, Peter

    2016-01-01

    In natural language processing, stand-off annotation uses the starting and ending positions of an annotation to anchor it to the text and stores the annotation content separately from the text. We address the fundamental problem of efficiently storing stand-off annotations when applying natural language processing on narrative clinical notes in electronic medical records (EMRs) and efficiently retrieving such annotations that satisfy position constraints. Efficient storage and retrieval of stand-off annotations can facilitate tasks such as mapping unstructured text to electronic medical record ontologies. We first formulate this problem into the interval query problem, for which optimal query/update time is in general logarithm. We next perform a tight time complexity analysis on the basic interval tree query algorithm and show its nonoptimality when being applied to a collection of 13 query types from Allen's interval algebra. We then study two closely related state-of-the-art interval query algorithms, proposed query reformulations, and augmentations to the second algorithm. Our proposed algorithm achieves logarithmic time stabbing-max query time complexity and solves the stabbing-interval query tasks on all of Allen's relations in logarithmic time, attaining the theoretic lower bound. Updating time is kept logarithmic and the space requirement is kept linear at the same time. We also discuss interval management in external memory models and higher dimensions. PMID:27478379

  19. Efficient Queries of Stand-off Annotations for Natural Language Processing on Electronic Medical Records

    PubMed Central

    Luo, Yuan; Szolovits, Peter

    2016-01-01

    In natural language processing, stand-off annotation uses the starting and ending positions of an annotation to anchor it to the text and stores the annotation content separately from the text. We address the fundamental problem of efficiently storing stand-off annotations when applying natural language processing on narrative clinical notes in electronic medical records (EMRs) and efficiently retrieving such annotations that satisfy position constraints. Efficient storage and retrieval of stand-off annotations can facilitate tasks such as mapping unstructured text to electronic medical record ontologies. We first formulate this problem into the interval query problem, for which optimal query/update time is in general logarithm. We next perform a tight time complexity analysis on the basic interval tree query algorithm and show its nonoptimality when being applied to a collection of 13 query types from Allen’s interval algebra. We then study two closely related state-of-the-art interval query algorithms, proposed query reformulations, and augmentations to the second algorithm. Our proposed algorithm achieves logarithmic time stabbing-max query time complexity and solves the stabbing-interval query tasks on all of Allen’s relations in logarithmic time, attaining the theoretic lower bound. Updating time is kept logarithmic and the space requirement is kept linear at the same time. We also discuss interval management in external memory models and higher dimensions. PMID:27478379

  20. 29 CFR 1913.10 - Rules of agency practice and procedure concerning OSHA access to employee medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... CFR 1910.1020(e). (2) For the purposes of this section, “personally identifiable employee medical... CFR part 1904, to death certificates, or to employee exposure records, including biological monitoring records treated by 29 CFR 1910.1020(c)(5) or by specific occupational safety and health standards...

  1. 29 CFR 1913.10 - Rules of agency practice and procedure concerning OSHA access to employee medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... CFR 1910.1020(e). (2) For the purposes of this section, “personally identifiable employee medical... CFR part 1904, to death certificates, or to employee exposure records, including biological monitoring records treated by 29 CFR 1910.1020(c)(5) or by specific occupational safety and health standards...

  2. 10 CFR 9.39 - Search and duplication provided without charge.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 10 Energy 1 2013-01-01 2013-01-01 false Search and duplication provided without charge. 9.39... § 9.39 Search and duplication provided without charge. (a) The NRC will search for agency records... the news media. (b) The NRC will search for agency records requested under § 9.23(b) without...

  3. 10 CFR 9.39 - Search and duplication provided without charge.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 10 Energy 1 2012-01-01 2012-01-01 false Search and duplication provided without charge. 9.39... § 9.39 Search and duplication provided without charge. (a) The NRC will search for agency records... the news media. (b) The NRC will search for agency records requested under § 9.23(b) without...

  4. 10 CFR 9.39 - Search and duplication provided without charge.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Search and duplication provided without charge. 9.39... § 9.39 Search and duplication provided without charge. (a) The NRC will search for agency records... the news media. (b) The NRC will search for agency records requested under § 9.23(b) without...

  5. 10 CFR 9.39 - Search and duplication provided without charge.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 1 2014-01-01 2014-01-01 false Search and duplication provided without charge. 9.39... § 9.39 Search and duplication provided without charge. (a) The NRC will search for agency records... the news media. (b) The NRC will search for agency records requested under § 9.23(b) without...

  6. 10 CFR 9.39 - Search and duplication provided without charge.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 10 Energy 1 2011-01-01 2011-01-01 false Search and duplication provided without charge. 9.39... § 9.39 Search and duplication provided without charge. (a) The NRC will search for agency records... the news media. (b) The NRC will search for agency records requested under § 9.23(b) without...

  7. Leading change: introducing an electronic medical record system to a paramedic service.

    PubMed

    Baird, Shawn; Boak, George

    2016-05-01

    Purpose Leaders in health-care organizations introducing electronic medical records (EMRs) face implementation challenges. The adoption of EMR by the emergency medical and ambulance setting is expected to provide wide-ranging benefits, but there is little research into the processes of adoption in this sector. The purpose of this study is to examine the introduction of EMR in a small emergency care organization and identify factors that aided adoption. Design/methodology/approach Semi-structured interviews with selected paramedics were followed up with a survey issued to all paramedics in the company. Findings The user interfaces with the EMR, and perceived ease of use, were important factors affecting adoption. Individual paramedics were found to have strong and varied preferences about how and when they integrated the EMR into their practice. As company leadership introduced flexibility of use, this enhanced both individual and collective ability to make sense of the change and removed barriers to acceptance. Research limitations/implications This is a case study of one small organization. However, there may be useful lessons for other emergency care organizations adopting EMR. Practical implications Leaders introducing EMR in similar situations may benefit from considering a sense-making perspective and responding promptly to feedback. Originality/value The study contributes to a wider understanding of issues faced by leaders who seek to implement EMRs in emergency medical services, a sector in which there has been to date very little research on this issue. PMID:27198703

  8. Assessment of Medical Records Module of Health Information System According to ISO 9241-10

    PubMed Central

    Ehteshami, Asghar; Sadoughi, Farahnaz; Saeedbakhsh, Saeed; Isfahani, Mahtab Kasaei

    2013-01-01

    Introduction Hospital managers and personnel need to Hospital Information System (HIS) to increase the efficiency and effectiveness in their organization. Accurate, appropriate, precise, timely, valid information, and Suitable Information system for their tasks is required and the basis for decision making in various levels of the hospital management, since, this study was conducted to Assess of Selected HIS in Isfahan University of Medical Science Hospitals According to ISO 9241-10. Methods This paper obtained from an applied, descriptive cross sectional study, in which the medical records module of IUMS selected HIS in Isfahan University of Medical Science affiliated seven hospitals were assessed with ISO 9241-10 questionnaire contained 7 principles and 74 items. The obtained data were analyzed with SPSS software and descriptive statistics were used to examine measures of central tendencies. Results The analysis of data revealed the following about the software: Suitability for user tasks, self descriptiveness, controllability by user, Conformity with user expectations, error tolerance, suitability for individualization, and suitability for user learning, respectively, was 68, 67, 70, 74, 69, 53, and 68 percent. Total compliance with ISO 9241-10 was 67 percent. Conclusion Information is the basis for policy and decision making in various levels of the hospital management. Consequently, it seems that HIS developers should decrease HIS errors and increase its suitability for tasks, self descriptiveness, controllability, conformity with user expectations, error tolerance, suitability for individualization, suitability for user learning. PMID:23572860

  9. Interview with Lawrence Weed, MD— The Father of the Problem-Oriented Medical Record Looks Ahead

    PubMed Central

    Jacobs, Lee

    2009-01-01

    I first met Lawrence Weed, MD, in 1972 when I was a third-year medical student at the University of Vermont. To this day I remember his passion for a disciplined approach to medical record documentation to optimize the care provided to each individual patient. Now, 35 years later, I was privileged to meet with Dr Weed at his home in Vermont. We discussed when he first was alerted to the nonscientific approach clinicians use to make decisions on patients. The rest of the interview time was spent with Dr Weed teaching me about the solution that he has spent the last 30 years designing and implementing. This interview is published to complement the editorial in the most recent issue of The Permanente Journal (Spring 2009;13[2]:85-7). We believe that in the era of health care reform and quality improvement initiatives, it is important that the medical community take a close look at Dr Weed's total approach decision-making information support defined in this interview. — Lee Jacobs, MD PMID:20740095

  10. Use of the Electronic Medical Record to Assess Pancreas Size in Type 1 Diabetes

    PubMed Central

    Virostko, John; Hilmes, Melissa; Eitel, Kelsey; Moore, Daniel J.; Powers, Alvin C.

    2016-01-01

    Aims This study harnessed the electronic medical record to assess pancreas volume in patients with type 1 diabetes (T1D) and matched controls to determine whether pancreas volume is altered in T1D and identify covariates that influence pancreas volume. Methods This study included 25 patients with T1D and 25 age-, sex-, and weight-matched controls from the Vanderbilt University Medical Center enterprise data warehouse. Measurements of pancreas volume were made from medical imaging studies using magnetic resonance imaging (MRI) or computed tomography (CT). Results Patients with T1D had a pancreas volume 47% smaller than matched controls (41.16 ml vs. 77.77 ml, P < 0.0001) as well as pancreas volume normalized by subject body weight, body mass index, or body surface area (all P < 0.0001). Pancreatic volume was smaller with a longer duration of T1D across the patient population (N = 25, P = 0.04). Additionally, four individual patients receiving multiple imaging scans displayed progressive declines in pancreas volume over time (~ 6% of volume/year), whereas five controls scanned a year apart did not exhibit a decline in pancreas size (P = 0.03). The pancreas was uniformly smaller on the right and left side of the abdomen. Conclusions Pancreas volume declines with disease duration in patients with T1D, suggesting a protracted pathological process that may include the exocrine pancreas. PMID:27391588

  11. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

    PubMed Central

    Singh, Hardeep; Thomas, Eric J.; Sittig, Dean F.; Wilson, Lindsey; Espadas, Donna; Khan, Myrna M.; Petersen, Laura A.

    2010-01-01

    Background: Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. Methods: We studied four alerts: hemoglobin A1c (HbA1c) ≥15%, positive hepatitis C antibody (HCV), prostate specific antigen (PSA) ≥15 ng/mL, and thyroid stimulating hormone (TSH) ≥ 15 mIU/L. An alert tracking system determined whether the alert was acknowledged (i.e. provider clicked on and opened the message) within two weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (e.g. patient contact, treatment etc.). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. Results: Between May 2008 and December 2008, 78,158 tests (HbA1c, HCV, TSH and PSA) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%) and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs. 10.1%; p =.13). Two-hundred two alerts (17.4% of 1163) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (OR: 7.35; 95% CI: 4.16-12.97) whereas alerts related to redundant tests were less likely to lack timely follow-up (OR: 0.24; 95% CI: 0.07-0.84). Conclusions: Safety concerns related to timely patient follow-up remain despite automated notification of non-life threatening abnormal laboratory results in the outpatient setting. PMID:20193832

  12. Does Wearable Medical Technology With Video Recording Capability Add Value to On-Call Surgical Evaluations?

    PubMed

    Gupta, Sameer; Boehme, Jacqueline; Manser, Kelly; Dewar, Jannine; Miller, Amie; Siddiqui, Gina; Schwaitzberg, Steven D

    2016-10-01

    Background Google Glass has been used in a variety of medical settings with promising results. We explored the use and potential value of an asynchronous, near-real time protocol-which avoids transmission issues associated with real-time applications-for recording, uploading, and viewing of high-definition (HD) visual media in the emergency department (ED) to facilitate remote surgical consults. Study Design First-responder physician assistants captured pertinent aspects of the physical examination and diagnostic imaging using Google Glass' HD video or high-resolution photographs. This visual media were then securely uploaded to the study website. The surgical consultation then proceeded over the phone in the usual fashion and a clinical decision was made. The surgeon then accessed the study website to review the uploaded video. This was followed by a questionnaire regarding how the additional data impacted the consultation. Results The management plan changed in 24% (11) of cases after surgeons viewed the video. Five of these plans involved decision making regarding operative intervention. Although surgeons were generally confident in their initial management plan, confidence scores increased further in 44% (20) of cases. In addition, we surveyed 276 ED patients on their opinions regarding concerning the practice of health care providers wearing and using recording devices in the ED. The survey results revealed that the majority of patients are amenable to the addition of wearable technology with video functionality to their care. Conclusions This study demonstrates the potential value of a medically dedicated, hands-free, HD recording device with internet connectivity in facilitating remote surgical consultation.

  13. Does Wearable Medical Technology With Video Recording Capability Add Value to On-Call Surgical Evaluations?

    PubMed

    Gupta, Sameer; Boehme, Jacqueline; Manser, Kelly; Dewar, Jannine; Miller, Amie; Siddiqui, Gina; Schwaitzberg, Steven D

    2016-10-01

    Background Google Glass has been used in a variety of medical settings with promising results. We explored the use and potential value of an asynchronous, near-real time protocol-which avoids transmission issues associated with real-time applications-for recording, uploading, and viewing of high-definition (HD) visual media in the emergency department (ED) to facilitate remote surgical consults. Study Design First-responder physician assistants captured pertinent aspects of the physical examination and diagnostic imaging using Google Glass' HD video or high-resolution photographs. This visual media were then securely uploaded to the study website. The surgical consultation then proceeded over the phone in the usual fashion and a clinical decision was made. The surgeon then accessed the study website to review the uploaded video. This was followed by a questionnaire regarding how the additional data impacted the consultation. Results The management plan changed in 24% (11) of cases after surgeons viewed the video. Five of these plans involved decision making regarding operative intervention. Although surgeons were generally confident in their initial management plan, confidence scores increased further in 44% (20) of cases. In addition, we surveyed 276 ED patients on their opinions regarding concerning the practice of health care providers wearing and using recording devices in the ED. The survey results revealed that the majority of patients are amenable to the addition of wearable technology with video functionality to their care. Conclusions This study demonstrates the potential value of a medically dedicated, hands-free, HD recording device with internet connectivity in facilitating remote surgical consultation. PMID:27335083

  14. Meeting the security requirements of electronic medical records in the ERA of high-speed computing.

    PubMed

    Alanazi, H O; Zaidan, A A; Zaidan, B B; Kiah, M L Mat; Al-Bakri, S H

    2015-01-01

    This study has two objectives. First, it aims to develop a system with a highly secured approach to transmitting electronic medical records (EMRs), and second, it aims to identify entities that transmit private patient information without permission. The NTRU and the Advanced Encryption Standard (AES) cryptosystems are secured encryption methods. The AES is a tested technology that has already been utilized in several systems to secure sensitive data. The United States government has been using AES since June 2003 to protect sensitive and essential information. Meanwhile, NTRU protects sensitive data against attacks through the use of quantum computers, which can break the RSA cryptosystem and elliptic curve cryptography algorithms. A hybrid of AES and NTRU is developed in this work to improve EMR security. The proposed hybrid cryptography technique is implemented to secure the data transmission process of EMRs. The proposed security solution can provide protection for over 40 years and is resistant to quantum computers. Moreover, the technique provides the necessary evidence required by law to identify disclosure or misuse of patient records. The proposed solution can effectively secure EMR transmission and protect patient rights. It also identifies the source responsible for disclosing confidential patient records. The proposed hybrid technique for securing data managed by institutional websites must be improved in the future. PMID:25481568

  15. Meeting the security requirements of electronic medical records in the ERA of high-speed computing.

    PubMed

    Alanazi, H O; Zaidan, A A; Zaidan, B B; Kiah, M L Mat; Al-Bakri, S H

    2015-01-01

    This study has two objectives. First, it aims to develop a system with a highly secured approach to transmitting electronic medical records (EMRs), and second, it aims to identify entities that transmit private patient information without permission. The NTRU and the Advanced Encryption Standard (AES) cryptosystems are secured encryption methods. The AES is a tested technology that has already been utilized in several systems to secure sensitive data. The United States government has been using AES since June 2003 to protect sensitive and essential information. Meanwhile, NTRU protects sensitive data against attacks through the use of quantum computers, which can break the RSA cryptosystem and elliptic curve cryptography algorithms. A hybrid of AES and NTRU is developed in this work to improve EMR security. The proposed hybrid cryptography technique is implemented to secure the data transmission process of EMRs. The proposed security solution can provide protection for over 40 years and is resistant to quantum computers. Moreover, the technique provides the necessary evidence required by law to identify disclosure or misuse of patient records. The proposed solution can effectively secure EMR transmission and protect patient rights. It also identifies the source responsible for disclosing confidential patient records. The proposed hybrid technique for securing data managed by institutional websites must be improved in the future.

  16. Realization of a universal patient identifier for electronic medical records through biometric technology.

    PubMed

    Leonard, D C; Pons, Alexander P; Asfour, Shihab S

    2009-07-01

    The technology exists for the migration of healthcare data from its archaic paper-based system to an electronic one, and, once in digital form, to be transported anywhere in the world in a matter of seconds. The advent of universally accessible healthcare data has benefited all participants, but one of the outstanding problems that must be addressed is how the creation of a standardized nationwide electronic healthcare record system in the United States would uniquely identify and match a composite of an individual's recorded healthcare information to an identified individual patients out of approximately 300 million people to a 1:1 match. To date, a few solutions to this problem have been proposed that are limited in their effectiveness. We propose the use of biometric technology within our fingerprint, iris, retina scan, and DNA (FIRD) framework, which is a multiphase system whose primary phase is a multilayer consisting of these four types of biometric identifiers: 1) fingerprint; 2) iris; 3) retina scan; and 4) DNA. In addition, it also consists of additional phases of integration, consolidation, and data discrepancy functions to solve the unique association of a patient to their medical data distinctively. This would allow a patient to have real-time access to all of their recorded healthcare information electronically whenever it is necessary, securely with minimal effort, greater effectiveness, and ease. PMID:19273015

  17. History of the Rochester Epidemiology Project: half a century of medical records linkage in a US population.

    PubMed

    Rocca, Walter A; Yawn, Barbara P; St Sauver, Jennifer L; Grossardt, Brandon R; Melton, L Joseph

    2012-12-01

    The Rochester Epidemiology Project (REP) has maintained a comprehensive medical records linkage system for nearly half a century for almost all persons residing in Olmsted County, Minnesota. Herein, we provide a brief history of the REP before and after 1966, the year in which the REP was officially established. The key protagonists before 1966 were Henry Plummer, Mabel Root, and Joseph Berkson, who developed a medical records linkage system at Mayo Clinic. In 1966, Leonard Kurland established collaborative agreements with other local health care providers (hospitals, physician groups, and clinics [primarily Olmsted Medical Center]) to develop a medical records linkage system that covered the entire population of Olmsted County, and he obtained funding from the National Institutes of Health to support the new system. In 1997, L. Joseph Melton III addressed emerging concerns about the confidentiality of medical record information by introducing a broad patient research authorization as per Minnesota state law. We describe how the key protagonists of the REP have responded to challenges posed by evolving medical knowledge, information technology, and public expectation and policy. In addition, we provide a general description of the system; discuss issues of data quality, reliability, and validity; describe the research team structure; provide information about funding; and compare the REP with other medical information systems. The REP can serve as a model for the development of similar research infrastructures in the United States and worldwide.

  18. Leveraging electronic health records to study pleiotropic effects on bipolar disorder and medical comorbidities

    PubMed Central

    Prieto, M L; Ryu, E; Jenkins, G D; Batzler, A; Nassan, M M; Cuellar-Barboza, A B; Pathak, J; McElroy, S L; Frye, M A; Biernacka, J M

    2016-01-01

    Patients with bipolar disorder (BD) have a high prevalence of comorbid medical illness. However, the mechanisms underlying these comorbidities with BD are not well known. Certain genetic variants may have pleiotropic effects, increasing the risk of BD and other medical illnesses simultaneously. In this study, we evaluated the association of BD-susceptibility genetic variants with various medical conditions that tend to co-exist with BD, using electronic health records (EHR) data linked to genome-wide single-nucleotide polymorphism (SNP) data. Data from 7316 Caucasian subjects were used to test the association of 19 EHR-derived phenotypes with 34 SNPs that were previously reported to be associated with BD. After Bonferroni multiple testing correction, P<7.7 × 10−5 was considered statistically significant. The top association findings suggested that the BD risk alleles at SNP rs4765913 in CACNA1C gene and rs7042161 in SVEP1 may be associated with increased risk of ‘cardiac dysrhythmias' (odds ratio (OR)=1.1, P=3.4 × 10−3) and ‘essential hypertension' (OR=1.1, P=3.5 × 10−3), respectively. Although these associations are not statistically significant after multiple testing correction, both genes have been previously implicated with cardiovascular phenotypes. Moreover, we present additional evidence supporting these associations, particularly the association of the SVEP1 SNP with hypertension. This study shows the potential for EHR-based analyses of large cohorts to discover pleiotropic effects contributing to complex psychiatric traits and commonly co-occurring medical conditions. PMID:27529678

  19. Leveraging electronic health records to study pleiotropic effects on bipolar disorder and medical comorbidities.

    PubMed

    Prieto, M L; Ryu, E; Jenkins, G D; Batzler, A; Nassan, M M; Cuellar-Barboza, A B; Pathak, J; McElroy, S L; Frye, M A; Biernacka, J M

    2016-01-01

    Patients with bipolar disorder (BD) have a high prevalence of comorbid medical illness. However, the mechanisms underlying these comorbidities with BD are not well known. Certain genetic variants may have pleiotropic effects, increasing the risk of BD and other medical illnesses simultaneously. In this study, we evaluated the association of BD-susceptibility genetic variants with various medical conditions that tend to co-exist with BD, using electronic health records (EHR) data linked to genome-wide single-nucleotide polymorphism (SNP) data. Data from 7316 Caucasian subjects were used to test the association of 19 EHR-derived phenotypes with 34 SNPs that were previously reported to be associated with BD. After Bonferroni multiple testing correction, P<7.7 × 10(-5) was considered statistically significant. The top association findings suggested that the BD risk alleles at SNP rs4765913 in CACNA1C gene and rs7042161 in SVEP1 may be associated with increased risk of 'cardiac dysrhythmias' (odds ratio (OR)=1.1, P=3.4 × 10(-3)) and 'essential hypertension' (OR=1.1, P=3.5 × 10(-3)), respectively. Although these associations are not statistically significant after multiple testing correction, both genes have been previously implicated with cardiovascular phenotypes. Moreover, we present additional evidence supporting these associations, particularly the association of the SVEP1 SNP with hypertension. This study shows the potential for EHR-based analyses of large cohorts to discover pleiotropic effects contributing to complex psychiatric traits and commonly co-occurring medical conditions. PMID:27529678

  20. An innovative approach to medical control: semiautomatic defibrillators with solid-state memory modules for recording cardiac arrest events.

    PubMed

    Cummins, R O; Austin, D; Graves, J R; Hambly, C

    1988-08-01

    We evaluated the use of microprocessor-based memory modules incorporated into automatic external defibrillators. These solid-state modules store information about each clinical use, including selected segments of the ECG rhythm and notations on defibrillator operation. A playback unit provides annotated printouts of the recorded information. The purpose of our evaluation was to determine whether this memory module could adequately support medical control "run-reviews" when compared with dualfunction (voice and ECG) tape recordings. A total of 41 resuscitation attempts by emergency medical technicians trained to defibrillate (EMT-Ds) were evaluated in five preselected performance areas: defibrillation skills, command and communication at the scene, patient assessment and support, safety, and speed. When performance was reviewed using the tape recordings, the average EMT-D performance score was 16.2 (maximum, 20); when reviewed using the printouts from the medical control modules, the average score, 7.2, was significantly lower (P less than .01). The lower scores with the medical control module occurred because not all five areas of skill could be evaluated adequately by the memory module approach. Assessment of the areas of communication/command at the scene, patient assessment/support, and safety required verbal tape recordings. The medical control module appeared superior to the tape recordings at providing a quick, convenient, and accurate evaluation of rhythm assessment, shock decisions, time intervals, and defibrillator performance. They make several features of medical control review easier and more convenient, and may encourage implementation of early defibrillation programs. We conclude, however, that medical control modules cannot replace on-scene tape recordings for adequate medical control of EMT-D programs. PMID:3394986