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Sample records for duplicate medical records

  1. 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…

  2. Nature and management of duplicate medication alerts.

    PubMed

    Heringa, Mette; Floor, Annemieke; Meijer, Willemijn M; De Smet, Peter A G M; Bouvy, Marcel L

    2015-07-01

    To investigate the nature of duplicate medication (DM) alerts, their management by community pharmacists, and potential characteristics of DM alerts that lead to interventions by pharmacists. Observational study in 53 community pharmacies. Each pharmacist registered the nature and management of 24 DM alerts on a structured form. On average, the clinical decision support systems generated 20.4 DM alerts per 100 dispensed drugs. In half of the 1272 registered alerts, the pharmacists judged that there was no risk for concurrent use of both prescriptions. In 32% of the alerts, the DM alert was generated for an intentional combination. In 17% of the alerts, there was a risk for unintentional concurrent use. In 32% of the alerts the pharmacists decided that one or more actions were needed: the electronic patient record was updated in 15% of the alerts and in 19% of the alerts the pharmacists performed an external action-for example, informing the patient or modifying the prescription (including 5 therapeutic prescription modifications and 22 logistic prescription modifications). Alerts concerning first dispensing were more likely to be followed by an external action than alerts concerning refills (40% vs 14%, P < .001). In community pharmacy, prescription modifications based on DM alerts are rare, but DM alerts lead with some regularity to other actions-for example, patient instruction and update of the electronic patient record. As the current DM alerts are diverse and nonspecific in detecting situations where external action is considered relevant, other ways of alerting should therefore be considered. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  3. 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.

  4. Your Medical Records

    MedlinePlus

    ... Surgery? A Week of Healthy Breakfasts Shyness Your Medical Records KidsHealth > For Teens > Your Medical Records A ... Records? en español Tus historias clínicas What Are Medical Records? Each time you climb up on a ...

  5. Your Medical Records

    MedlinePlus

    ... sometimes, but many health care providers now keep electronic records. You might hear medical people call these EHRs — short for electronic health records . Electronic records make it easier for ...

  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. 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…

  8. 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…

  9. Confidentiality and medical records

    PubMed Central

    Jones, R. V. H.; Richards, S. Jane

    1978-01-01

    Protecting confidential information disclosed to doctors has been one of the most important ethical traditions of the medical profession. However, the patient's right to such confidentiality is threatened because it is legally unclear how far ownership by Government of the paper on which NHS records are kept or of the computer system in which they are stored confers right of access. We hope the medical profession will examine this problem urgently and offer some suggestions as to how patients' confidences can continue to be protected in the future. PMID:702427

  10. Adopting electronic medical records

    PubMed Central

    Price, Morgan; Singer, Alex; Kim, Julie

    2013-01-01

    Abstract Objective To understand the key challenges to adoption of advanced features of electronic medical records (EMRs) in office practice, and to better understand these challenges in a Canadian context. Design Mixed-methods study. Setting Manitoba. Participants Health care providers and staff in 5 primary care offices. Methods Level of EMR adoption was assessed, and field notes from interviews and discussion groups were qualitatively analyzed for common challenges and themes across all sites. Main findings Fifty-seven interviews and 4 discussion groups were conducted from November 2011 to January 2012. Electronic medical record adoption scores ranged from 2.3 to 3.0 (out of a theoretical maximum of 5). Practices often scored lower than expected on use of decision support, providing patients with access to their own data, and use of practice-reporting tools. Qualitative analysis showed there were ceiling effects to EMR adoption owing to how the EMR was implemented, the supporting eHealth infrastructure, lack of awareness or availability of EMR functionality, and poor EMR data quality. Conclusion Many practitioners used their EMRs as “electronic paper records” and were not using advanced features of their EMRs that could further enhance practice. Data-quality issues within the EMRs could affect future attempts at using these features. Education and quality improvement activities to support data quality and EMR optimization are likely needed to support practices in maximizing their use of EMRs. PMID:23851560

  11. 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

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

    PubMed

    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.

  13. Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

    PubMed

    Wetterneck, Tosha B; Walker, James M; Blosky, Mary Ann; Cartmill, Randi S; Hoonakker, Peter; Johnson, Mark A; Norfolk, Evan; Carayon, Pascale

    2011-01-01

    To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors. CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs). Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors. Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered. Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.

  14. Duplicative medications in patients who visit multiple medical institutions among the insured of a corporate health insurance society in Japan.

    PubMed

    Kinoshita, Hiroki; Kobayashi, Yasuki; Fukuda, Takashi

    2008-01-01

    The objective of this paper is to describe the frequency of duplicative medication use and to estimate the drug cost associated with duplicative medications in patients who visit multiple medical institutions in Japan. The subjects of this study were insurants of a corporate health insurance society. We examined claims of insurants who received prescriptions from multiple medical institutions in April 2002. We examined characteristics of insurants who received duplicative medications and calculated the cost of duplicated drugs. 8.8% received drugs with the same mechanism of action for overlapping administration periods. In terms of comparison among three age groups, 0-19 years old, 20-69 years old, and 70 years old or older, the percentage was higher in 0-19-year-old patients than in the other age groups. The cost of duplicated drugs was found to be 0.7% or 0.5% of the total drug cost, when calculated with higher-priced drugs and lower-priced drugs, respectively. This study suggests that pediatric and teenage patients as well as elderly patients require prudent management of medication to avoid duplicative medications and that at least an estimated 5.2-7.2 billion yen may be saved if duplicative medications can be completely eliminated nationwide.

  15. Patient access to medical records.

    PubMed

    Mair, J L

    1996-01-01

    The issue of, and access to, medical records has been a contentious matter for some years in Australia. The recent High Court decision of Breen v Williams has clarified the law nationwide. The High Court confirmed that the ownership of medical records is vested in the creator of the records. The High Court further held that a patient has no right at law to access his or her medical records in the absence of any statute granting such a right, or other legal process.

  16. Social network analysis of duplicative prescriptions: One-month analysis of medical facilities in Japan.

    PubMed

    Takahashi, Yoshimitsu; Ishizaki, Tatsuro; Nakayama, Takeo; Kawachi, Ichiro

    2016-03-01

    Duplicative prescriptions refer to situations in which patients receive medications for the same condition from two or more sources. Health officials in Japan have expressed concern about medical "waste" resulting from this practices. We sought to conduct descriptive analysis of duplicative prescriptions using social network analysis and to report their prevalence across ages. We analyzed a health insurance claims database including 1.24 million people from December 2012. Through social network analysis, we examined the duplicative prescription networks, representing each medical facility as nodes, and individual prescriptions for patients as edges. The prevalence of duplicative prescription for any drug class was strongly correlated with its frequency of prescription (r=0.90). Among patients aged 0-19, cough and colds drugs showed the highest prevalence of duplicative prescriptions (10.8%). Among people aged 65 and over, antihypertensive drugs had the highest frequency of prescriptions, but the prevalence of duplicative prescriptions was low (0.2-0.3%). Social network analysis revealed clusters of facilities connected via duplicative prescriptions, e.g., psychotropic drugs showed clustering due to a few patients receiving drugs from 10 or more facilities. Overall, the prevalence of duplicative prescriptions was quite low - less than 10% - although the extent of the problem varied by drug class and age group. Our approach illustrates the potential utility of using a social network approach to understand these practices. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  17. Standards in medical record keeping.

    PubMed

    Mann, Robin; Williams, John

    2003-01-01

    Medical records serve many functions but their primary purpose is to support patient care. The RCP Health Informatics Unit (HIU) has found variability in the quality of records and discharge summaries in England and Wales. There is currently a major drive to computerise medical records across the NHS, but without improvement in the quality of paper records the full benefits of computerisation are unlikely to be realised. The onus for improving records lies with individual health professionals. Structuring the record can bring direct benefits to patients by improving patient outcomes and doctors' performance. The HIU has reviewed the literature and is developing evidence-based standards for record keeping including the structure of the record. The first draft of these standards has been released for consultation purposes. This article is the first of a series that will describe the standards, and the evidence behind them.

  18. Duplicate Publications in Korean medical journals indexed in KoreaMed.

    PubMed

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

    2008-02-01

    Duplicate publication is considered unethical. It has several negative impacts. To estimate the frequency and characteristics of duplicate publications in Korean medical journals, we reviewed some portion of Korean journal articles. Among 9,030 articles that are original articles indexed in KoreaMed from January to December 2004, 455 articles (5%) were chosen by random sampling. PubMed, Google scholar, KMbase, and KoreaMed were searched by two librarians. Three authors reviewed titles, abstracts, and full text of index articles and suspected articles independently. Point of disagreement were reconciled by discussion. Criteria for a duplicate publication defined by editors of cardiothoracic journals and International Committee of Medical Journal Editors were used. A total of 455 articles were evaluated, of which 27 (5.93%) index articles were identified with 29 duplicate articles. Among 27 index articles, 1 was quadruple publication and 26 were double publications. Of 29 duplicated articles, 19 were classified as copy, 4 as fragmentation, and 6 as disaggregation. The proportion of duplicate publications in Korean medical journals appears to be higher than expected. Education on publication ethics to researchers is needed.

  19. Medical records and access thereto.

    PubMed

    McQuoid-Mason, D

    1996-01-01

    Medical records are essential tools in the practice of medicine. They are important in the planning and monitoring of patient care and for the protection of the legal interests of patients, hospitals and doctors. There is a legal duty on doctors to maintain confidentiality and failure to do so may result in an action for invasion of privacy, defamation or even breach of contract. There are, however, exceptions to this rule. There are procedural remedies available to obtain access to medical records where they are relevant to civil or criminal proceedings. There are also constitutional provisions under the Interim and Working Draft Constitutions which may allow such access. The former only applies to records held by the state while the latter applies to both state and privately held records. Ownership of medical records usually vests in the doctor or institution treating the patient, but such ownership is custodial rather than absolute. Patient records should be accurate, objective and contemporaneous. The international trend is to allow patients to inspect their records and to allow them to make copies thereof. It is submitted that given the provisions of the Interim and Working Draft Constitutions the same should apply in South Africa.

  20. Tracking medication information across medical records.

    PubMed

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

    2009-11-14

    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. approximately recall approximately 87%. The output is a timeline display of the drugs which the patient has been taking.

  1. 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

  2. 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 each...

  3. 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 each...

  4. 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 each...

  5. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 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 each...

  6. 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 each...

  7. 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 only...

  8. 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 only...

  9. 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 only...

  10. 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 only...

  11. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 2 2011-07-01 2011-07-01 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 only...

  12. 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 individual is entitled to have access to any medical records about himself in Privacy Act Record Systems...

  13. 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 individual is entitled to have access to any medical records about himself in Privacy Act Record Systems...

  14. 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 individual is entitled to have access to any medical records about himself in Privacy Act Record Systems...

  15. 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 individual is entitled to have access to any medical records about himself in Privacy Act Record Systems...

  16. 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 individual is entitled to have access to any medical records about himself in Privacy Act Record Systems...

  17. 36 CFR 1238.16 - What are the microfilming requirements for temporary records, duplicates, and user copies?

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... requirements for temporary records, duplicates, and user copies? 1238.16 Section 1238.16 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS ADMINISTRATION RECORDS MANAGEMENT MICROFORMS RECORDS MANAGEMENT Microfilming Standards § 1238.16 What are the microfilming requirements for temporary...

  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... and Covered Birth Defects § 17.905 Medical records. Copies of medical records generated outside VA...

  19. 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... and Covered Birth Defects § 17.905 Medical records. Copies of medical records generated outside VA...

  20. 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... and Covered Birth Defects § 17.905 Medical records. Copies of medical records generated outside VA...

  1. 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... and Covered Birth Defects § 17.905 Medical records. Copies of medical records generated outside VA...

  2. 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 be...

  3. 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 individual...

  4. 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 be...

  5. 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 be...

  6. 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 be...

  7. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 5 2011-07-01 2011-07-01 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 individual...

  8. 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 be...

  9. Why a shared care record is an official medical record.

    PubMed

    Gu, Yulong; Orr, Martin; Warren, Jim; Humphrey, Gayl; Day, Karen; Tibby, Sarah; Fitzpatrick, Jo

    2013-10-18

    The literature describes three categories of health records: the Official Medical Records held by healthcare providers, Personal Health Records owned by patients, and--a possible in between case--the Shared Care Record. New complications and challenges arise with electronic storage of this latter class of record; for instance, an electronic shared care record may have multiple authors, which presents challenges regarding the roles and responsibilities for record-keeping. This article discusses the definitions and implementations of official medical records, personal health records and shared care records. We also consider the case of a New Zealand pilot of developing and implementing a shared care record in the National Shared Care Planning Programme. The nature and purpose of an official medical record remains the same whether in paper or electronic form. We maintain that a shared care record is an official medical record; it is not a personal health record that is owned and controlled by patients, although it is able to be viewed and interacted with by patients. A shared care record needs to meet the same criteria for medico-legal and ethical duties in the delivery of shared care as pertain to any official medical record.

  10. 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 Agency...

  11. 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 the...

  12. 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 the...

  13. 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 Agency...

  14. 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 Agency...

  15. 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 the...

  16. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 14 Aeronautics and Space 2 2010-01-01 2010-01-01 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 the...

  17. 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 the...

  18. 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 Agency...

  19. 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 Agency...

  20. Finance, pharmaceuticals, providers issue brief: medical records.

    PubMed

    Hackney, C

    2000-06-01

    Medical records confidentiality has blossomed into one of the bigger state and federal topics of the 2000 legislative session. The issue has evolved to encompass regulation of the access to records aspect of health privacy, rather than 1999's stressing the importance of records privacy altogether. This shift is placing more emphasis on "who" (insurers, corporations, researchers, etc.) gets right of entry to sensitive and personally revealing medical records, as opposed to "what" (which file types will be private, which will not).

  1. 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.

  2. Medical records in equine veterinary practice.

    PubMed

    Werner, Susan H

    2009-12-01

    Quality medical records are the cornerstone of successful equine veterinary practice. The scope and integrity of the information contained in a practice's medical records influence the quality of patient care and client service and affect liability risk, practice productivity, and overall practice value.

  3. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... medical and psychological records if that access could have an adverse affect on the mental or physical... located may afford special protection to certain medical records (e.g., drug and alcohol abuse treatment... time of the treatment or consultation was 15, 16, or 17 years old; the treatment or consultation...

  4. Basic Workshops for Medical Record Clerical Personnel.

    ERIC Educational Resources Information Center

    Intermountain Regional Medical Program, Salt Lake City, UT.

    This curriculum guide is an outline of the content for basic workshop training sessions of hospital medical record personnel. Following a two-page topical outline of five content areas, there is a detailed presentation of this content as follows: (1) the medical record and its contribution to patient care (Joint Commission for Accreditation of…

  5. Basic Workshops for Medical Record Clerical Personnel.

    ERIC Educational Resources Information Center

    Intermountain Regional Medical Program, Salt Lake City, UT.

    This curriculum guide is an outline of the content for basic workshop training sessions of hospital medical record personnel. Following a two-page topical outline of five content areas, there is a detailed presentation of this content as follows: (1) the medical record and its contribution to patient care (Joint Commission for Accreditation of…

  6. 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 Medical...

  7. [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.

  8. Access to Personal Medical Records.

    ERIC Educational Resources Information Center

    Weisenstein, Sharon

    Whether individuals should be allowed to see and correct their health records evokes controversy that revolves about citizens' rights to know what information is kept on them, society's duty to protect individuals' and doctors' rights, and the rights of employers and other parties to maintain the confidentiality of their files. A review of the…

  9. 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.

  10. 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.

  11. Medical Records and Health Information Technicians

    MedlinePlus

    ... information with other professionals such as physicians and finance personnel. Quick Facts: Medical Records and Health Information ... requirements with other professionals such as physicians and finance personnel. Technical skills. Health information technicians must be ...

  12. 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.

  13. 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.

  14. Online detection of potential duplicate medications and changes of physician behavior for outpatients visiting multiple hospitals using national health insurance smart cards in Taiwan.

    PubMed

    Hsu, Min-Huei; Yeh, Yu-Ting; Chen, Chien-Yuan; Liu, Chien-Hsiang; Liu, Chien-Tsai

    2011-03-01

    Doctor shopping (or hospital shopping), which means changing doctors (or hospitals) without professional referral for the same or similar illness conditions, is common in Hong Kong, Taiwan and Japan. Due to the lack of infrastructure for sharing health information and medication history among hospitals, doctor-shopping patients are more likely to receive duplicate medications and suffer adverse drug reactions. The Bureau of National Health Insurance (BNHI) adopted smart cards (or NHI-IC cards) as health cards in Taiwan. With their NHI-IC cards, patients can freely access different medical institutions. Because an NHI-IC card carries information about a patient's prescribed medications received from different hospitals nationwide, we used this system to address the problem of duplicate medications for outpatients visiting multiple hospitals. A computerized physician order entry (CPOE) system was enhanced with the capability of accessing NHI-IC cards and providing alerts to physicians when the system detects potential duplicate medications at the time of prescribing. Physician responses to the alerts were also collected to analyze changes in physicians' behavior. Chi-square tests and two-sided z-tests with Bonferroni adjustments for multiple comparisons were used to assess statistical significance of differences in actions taken by physicians over the three months. The enhanced CPOE system for outpatient services was implemented and installed at the Pediatric and Urology Departments of Taipei Medical University Wan-Fang Hospital in March 2007. The "Change Log" that recorded physician behavior was activated during a 3-month study period from April to June 2007. In 67.93% of patient visits, the physicians read patient NHI-IC cards, and in 16.76% of the reads, the NHI-IC card contained at least one prescribed medication that was taken by the patient. Among the prescriptions issued by physicians, on average, there were 2.36% prescriptions containing at least one

  15. Defining the Effect of the 16p11.2 Duplication on Cognition, Behavior, and Medical Comorbidities.

    PubMed

    D'Angelo, Debra; Lebon, Sébastien; Chen, Qixuan; Martin-Brevet, Sandra; Snyder, LeeAnne Green; Hippolyte, Loyse; Hanson, Ellen; Maillard, Anne M; Faucett, W Andrew; Macé, Aurélien; Pain, Aurélie; Bernier, Raphael; Chawner, Samuel J R A; David, Albert; Andrieux, Joris; Aylward, Elizabeth; Baujat, Genevieve; Caldeira, Ines; Conus, Philippe; Ferrari, Carrina; Forzano, Francesca; Gérard, Marion; Goin-Kochel, Robin P; Grant, Ellen; Hunter, Jill V; Isidor, Bertrand; Jacquette, Aurélia; Jønch, Aia E; Keren, Boris; Lacombe, Didier; Le Caignec, Cédric; Martin, Christa Lese; Männik, Katrin; Metspalu, Andres; Mignot, Cyril; Mukherjee, Pratik; Owen, Michael J; Passeggeri, Marzia; Rooryck-Thambo, Caroline; Rosenfeld, Jill A; Spence, Sarah J; Steinman, Kyle J; Tjernagel, Jennifer; Van Haelst, Mieke; Shen, Yiping; Draganski, Bogdan; Sherr, Elliott H; Ledbetter, David H; van den Bree, Marianne B M; Beckmann, Jacques S; Spiro, John E; Reymond, Alexandre; Jacquemont, Sébastien; Chung, Wendy K

    2016-01-01

    The 16p11.2 BP4-BP5 duplication is the copy number variant most frequently associated with autism spectrum disorder (ASD), schizophrenia, and comorbidities such as decreased body mass index (BMI). To characterize the effects of the 16p11.2 duplication on cognitive, behavioral, medical, and anthropometric traits and to understand the specificity of these effects by systematically comparing results in duplication carriers and reciprocal deletion carriers, who are also at risk for ASD. This international cohort study of 1006 study participants compared 270 duplication carriers with their 102 intrafamilial control individuals, 390 reciprocal deletion carriers, and 244 deletion controls from European and North American cohorts. Data were collected from August 1, 2010, to May 31, 2015 and analyzed from January 1 to August 14, 2015. Linear mixed models were used to estimate the effect of the duplication and deletion on clinical traits by comparison with noncarrier relatives. Findings on the Full-Scale IQ (FSIQ), Nonverbal IQ, and Verbal IQ; the presence of ASD or other DSM-IV diagnoses; BMI; head circumference; and medical data. Among the 1006 study participants, the duplication was associated with a mean FSIQ score that was lower by 26.3 points between proband carriers and noncarrier relatives and a lower mean FSIQ score (16.2-11.4 points) in nonproband carriers. The mean overall effect of the deletion was similar (-22.1 points; P < .001). However, broad variation in FSIQ was found, with a 19.4- and 2.0-fold increase in the proportion of FSIQ scores that were very low (≤40) and higher than the mean (>100) compared with the deletion group (P < .001). Parental FSIQ predicted part of this variation (approximately 36.0% in hereditary probands). Although the frequency of ASD was similar in deletion and duplication proband carriers (16.0% and 20.0%, respectively), the FSIQ was significantly lower (by 26.3 points) in the duplication probands with ASD. There also were

  16. 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... medical and psychological records if that access could have an adverse affect on the mental or physical... practitioner. If it is medically indicated that access could have an adverse mental or physical effect on...

  17. Medical Services: Nursing Records and Reports

    DTIC Science & Technology

    2007-11-02

    Record—Nursing Discharge Summary) • 2–11, page 5 SF 511 (Clinical Record—Vital Signs Record) • 2–12, page 6 SF 536 (Clinical Record— Pediatric Nursing...Notes) • 2–13, page 6 SF 537 (Medical Record— Pediatric Graphic Chart) • 2–14, page 6 SF 539 (Medical Record—Abbreviated Medical Record) • 2–15, page 6...the 24–hour total of the patient’s intake and output. 2–13. SF 536 (Clinical Record— Pediatric Nursing Notes) This form may be used for pediatric

  18. 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

  19. MEDRIS: The Problem Oriented Electronic Medical Record in Medical Education

    PubMed Central

    Rifat, Sami F.; Robert, Shanthi; Trace, David; Prakash, Sanjeev; Naeymi-Rad, Frank; Barnett, David; Pannicia, Gregory; Hammergren, David; Carmony, Lowell; Evens, Martha

    1990-01-01

    MEDRIS (The Medical Record Interface System) is an object oriented HyperCard interface designed to help physicians enter patient information as comfortably and naturally as possible. It can function as a stand alone system producing its own reports or serve as an interface to a medical expert system (e.g., MEDAS). MEDRIS plays an important role in the clinical education of medical students at the Chicago Medical School. MEDRIS portrays an intuitive, graphically oriented system that will provide a learning environment for the problem oriented medical record (POMR) that forms the basis of the structure of the history and physical exam. The enthusiasm shown by the medical students for this project has garnered support for including MEDRIS in the curriculum of the Introduction to Clinical Medicine course this semester. MEDRIS, developed using HyperCard, can be used as a tool not only for teaching POMR and physical diagnosis, but also computer literacy.

  20. Why facilitate patient access to medical records.

    PubMed

    Ferreira, Ana; Correia, Ana; Silva, Ana; Corte, Ana; Pinto, Ana; Saavedra, Ana; Pereira, Ana Luís; Pereira, Ana Filipa; Cruz-Correia, Ricardo; Antunes, Luís Filipe

    2007-01-01

    The wider use of healthcare information systems and the easier integration and sharing of patient clinical information can facilitate a wider access to medical records. The main goal of this paper is to perform a systematic review to analyze published work that studied the impact of facilitating patients' access to their medical record. Moreover, this review includes the analysis of the potential benefits and drawbacks on patient attitudes, doctor-patient relationship and on medical practice. In order to fill a gap in terms of the electronic medical record (EMR) impact within this issue, this review will focus on the use of EMR for patients to access their medical records as well as the advantages and disadvantages that this can bring. The articles included in the study were identified using MEDLINE and Scopus databases and revised according to their title and abstract and, afterwards, their full text was read considering inclusion and exclusion criteria. From the 165 articles obtained in MEDLINE a total of 12 articles were selected. From Scopus, 2 articles were obtained, so a total of 14 articles were included in the review. The studies revealed that patients' access to medical records can be beneficial for both patients and doctors, since it enhances communication between them whilst helping patients to better understand their health condition. The drawbacks (for instance causing confusion and anxiety to patients) seem to be minimal. However, patients continue to show concerns about confidentiality and understanding what is written in their records. The studies showed that the use of EMR can bring several advantages in terms of security solutions as well as improving the correctness and completeness of the patient records.

  1. Warfarin and Rivaroxaban Duplication: A Case Report and Medication Error Analysis.

    PubMed

    Fusco, Julie A; Paulus, Eric J; Shubat, Alexandra R; Miah, Sharminara

    2015-12-01

    A 62-year-old African American man received unintentional duplicate anticoagulation therapy with warfarin 5 mg and rivaroxaban 20 mg daily for the treatment of recurrent pulmonary embolism. The patient presented to the anticoagulation clinic 6 days after hospital discharge with an International Normalized Ratio (INR) of 2.3 and he was instructed to continue warfarin 5 mg daily. Seven days later, he returned to the clinic with an INR >8.0 using a point-of-care device. He denied any signs or symptoms of bleeding. During the interview, he reported starting a new medication for neuropathy 5 days earlier. The clinical pharmacist contacted the dispensing pharmacy and determined rivaroxaban 20 mg was the new medication. The patient denied receiving new prescription counseling at the dispensing pharmacy. Because rivaroxaban can falsely elevate INR results, the actual INR value was unknown. To minimize the risk for recurrent venous thromboembolism, vitamin K was not administered and no warfarin doses were held. Rather, the patient was instructed to stop rivaroxaban and reduce the warfarin dose. Five days later, the patient returned with an INR of 4.3. He still had not experienced any signs or symptoms of bleeding. The patient was quickly stabilized on a warfarin maintenance dose of 22.5 mg weekly. The anticoagulation clinic pharmacist notified management at the clinic and at the dispensing pharmacy in an effort to identify process errors and prevent additional incidents.

  2. Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

    PubMed

    Stewart, Autumn L; Lynch, Kevin J

    2012-01-01

    To describe the types and causes of medication discrepancies in the electronic medical record identified by pharmacist medication reconciliation during outpatient medical visits and to identify patient characteristics associated with the presence of discrepancies. Observational case series study. Indigent primary care clinic in Pittsburgh, PA, from April 2009 to May 2010. 219 adults presenting for follow-up medical visits and self-reporting medication use. Medication reconciliation as part of patient interview and concurrent chart review. Frequency, types, and reasons for medication discrepancies and demographic variables, patient knowledge, and adherence. Of 219 patients interviewed, 162 (74%) had at least one discrepancy. The most common type of discrepancy was an incorrect medication documented on the chart. The most common reasons included over-the-counter (OTC) use of medications and patients not reporting use of medications. The presence of one or more medication discrepancies was associated with the use of three or more medications. Patient factors such as gender, age, and race were not associated with discrepancies. Patients able to recall the strength for more than 75% of their medications had fewer discrepancies, while knowledge of the medication name, indication, or regimen had no association with discrepancies. Pharmacists play a critical role in identifying discrepancies between charted medication lists and self-reported medication use, independent of adherence. Inaccuracies in charted medications are frequent and often are related to use of OTC therapies and lack of communication and documentation during physician office visits. Knowledge of patient-related variables and other reasons for discrepancies may be useful in identifying patients at greatest risk for discrepancies and interventions to prevent and resolve them.

  3. Reading the medical record. I. Analysis of physicians' ways of reading the medical record.

    PubMed

    Nygren, E; Henriksson, P

    1992-01-01

    Physicians were interviewed about their routines in everyday use of the medical record. From the interviews, we conclude that the medical record is a well functioning working instrument for the experienced physician. Using the medical record as a basis for decision making involves interpretation of format, layout and other textural features of the type-written data. Interpretation of these features provides effective guidance in the process of searching, reading and assessing the relevance of different items of information in the record. It seems that this is a skill which is an integrated part of diagnostic expertise. This skill plays an important role in decision making based on the large amount of information about a patient, which is exhibited to the reader in the medical record. This finding has implications for the design of user interfaces for reading computerized medical records.

  4. Consultation of medical narratives in the electronic medical record.

    PubMed

    Tange, H J

    1999-12-01

    This article presents an overview of a research project concerning the consultation of medical narratives in the electronic medical record (EMR). It describes an analysis of user needs, the design and implementation of a prototype EMR system, and the evaluation of the ease of consultation of medical narratives when using this system. In a questionnaire survey, 85 hospital physicians judged the quality of their paper-based medical record with respect to data entry, information retrieval and some other aspects. Participants were more positive about the paper medical record than the literature suggests. They wished to maintain the flexibility of data entry but indicated the need to improve the retrieval of information. A prototype EMR system was developed to facilitate the consultation of medical narratives. These parts were divided into labeled segments that could be arranged source-oriented and problem-oriented. This system was used to evaluate the ease of information retrieval of 24 internists and 12 residents at a teaching hospital when using free-text medical narratives divided at different levels of detail. They solved, without time pressure, some predefined problems concerning three voluminous, inpatient case records. The participants were randomly allocated to a sequence that was balanced by patient case and learning effect. The division of medical narratives affected speed, but not completeness of information retrieval. Progress notes divided into problem-related segments could be consulted 22% faster than when undivided. Medical history and physical examination divided into segments at organ-system level could be consulted 13% faster than when divided into separate questions and observations. These differences were statistically significant. The fastest divisions were also appreciated as the best combination of easy searching and best insight in the patient case. The results of our evaluation study suggest a trade-off between searching and reading: too much

  5. The psychiatric medical record, HIPAA, and the use of electronic medical records.

    PubMed

    Houston, Michael

    2010-01-01

    This article addresses the practical and legal issues related to the psychiatric medical record, with an emphasis on the issues related to confidentiality. Implications of HIPAA (Health Insurance Portability and Accountability Act) legislation for the practice of child and adolescent psychiatry are addressed. The advantages and disadvantages of electronic medical records are reviewed, with guidelines for selecting software for solo and group practices.

  6. [Reliability of Primary Care computerised medication records].

    PubMed

    García-Molina Sáez, Celia; Urbieta Sanz, Elena; Madrigal de Torres, Manuel; Piñera Salmerón, Pascual; Pérez Cárceles, María D

    2016-03-01

    To quantify and to evaluate the reliability of Primary Care (PC) computerised medication records of as an information source of patient chronic medications, and to identify associated factors with the presence of discrepancies. A descriptive cross-sectional study. General Referral Hospital in Murcia. Patients admitted to the cardiology-chest diseases unit, during the months of February to April 2013, on home treatment, who agreed to participate in the study. Evaluation of the reliability of Primary Care computerised medication records by analysing the concordance, by identifying discrepancies, between the active medication in these records and that recorded in pharmacist interview with the patient/caregiver. Identification of associated factors with the presence of discrepancies was analysed using a multivariate logistic regression. The study included a total of 308 patients with a mean of 70.9 years (13.0 SD). The concordance of active ingredients was 83.7%, and this decreased to 34.7% when taking the dosage into account. Discrepancies were found in 97.1% of patients. The most frequent discrepancy was omission of frequency (35.6%), commission (drug added unjustifiably) (14.6%), and drug omission (12.7%). Age older than 65 years (1.98 [1.08 to 3.64]), multiple chronic diseases (1.89 [1.04 to 3.42]), and have a narcotic or psychotropic drug prescribed (2.22 [1.16 to 4.24]), were the factors associated with the presence of discrepancies. Primary Care computerised medication records, although of undoubted interest, are not be reliable enough to be used as the sole source of information on patient chronic medications when admitted to hospital. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

  7. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... have an adverse effect on the mental or physical health of the individual. Normally, this determination... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... health information established by HIPAA. (2) DOD Directive 6025.18-R prescribes the uses and...

  8. 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.

  9. [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.

  10. 20 CFR 401.55 - Access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 20 Employees' Benefits 2 2010-04-01 2010-04-01 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...

  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 individual's...

  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 procedures...

  13. 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 individual's...

  14. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 37 Patents, Trademarks, and Copyrights 1 2010-07-01 2010-07-01 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 individual's...

  15. 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... (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 and...

  16. Intelligent consumer-centric electronic medical record.

    PubMed

    Luo, Gang; Thomas, Selena B; Tang, Chunqiang

    2009-01-01

    Web-based, consumer-centric electronic medical records (CEMRs) are currently undergoing widespread deployment. Existing CEMRs, however, have limited intelligence and cannot satisfy users' many needs. This paper proposes the concept of intelligent CEMR. We introduce and extend expert system and web search technology into the CEMR domain. The resulting intelligent CEMRs can automatically provide users with personalized healthcare information to facilitate their daily activities. We use automatic home medical product recommendation as a concrete application to demonstrate the benefits offered by intelligent CEMRs.

  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. Recent perspectives of electronic medical record systems.

    PubMed

    Zhang, Xiao-Ying; Zhang, Peiying

    2016-06-01

    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.

  19. Rosie the Riveter's Wartime Medical Records

    PubMed Central

    Collen, Morris F; Culp, Bryan; Debley, Tom

    2008-01-01

    On October 24, 2000, the Rosie the Riveter World War II/Home Front National Historical Park was established in Richmond, CA to commemorate in a substantial way the wartime women workers in the shipyards. A review of the 1942–1945 published case reports from the medical records of women who worked in the Kaiser Shipyards in Richmond, found that the women who helped build ships for the war effort suffered many of the same medical problems as the men with whom they worked. PMID:21331218

  20. Rosie the Riveter's Wartime Medical Records.

    PubMed

    Collen, Morris F; Culp, Bryan; Debley, Tom

    2008-01-01

    On October 24, 2000, the Rosie the Riveter World War II/Home Front National Historical Park was established in Richmond, CA to commemorate in a substantial way the wartime women workers in the shipyards. A review of the 1942-1945 published case reports from the medical records of women who worked in the Kaiser Shipyards in Richmond, found that the women who helped build ships for the war effort suffered many of the same medical problems as the men with whom they worked.

  1. Computer Assisted Medical Record Documentation-Hyperalimentation

    PubMed Central

    Guritz, Gary A.; Brier, Kenneth Leo; Buth, Jonathan A.

    1985-01-01

    A microcomputer total parenteral nutrition (TPN) (hyperalimentation) program was developed to provide individualized intravenous nutritional support. The microcomputer TPN program assisted in preliminary nutritional assessment and enabled the pharmacist to manipulate different solutions in achieving a final product. Computerized calculations are based on caloric needs, nitrogen requirements and solutions available. The resultant program allowed greater clinical involvement by the pharmacist and enabled complete medical record documentation of the nutritional regimen.

  2. 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.

  3. Access to Medical and Exposure Records

    DTIC Science & Technology

    2001-01-01

    Access to Medical and Exposure Records U.S. Department of Labor Occupational Safety and Health Administration OSHA 3110 2001 (Revised) U.S...Department of Labor Elaine L. Chao, Secretary Occupational Safety and Health Administration John L. Henshaw, Assistant Secretary This booklet provides a...standards and the Occupational Safety and Health Act. Because interpretations and enforcement policy may change over time, the best sources for

  4. 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…

  5. 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…

  6. [Electronic medical record--interface specifications with medical informatics systems].

    PubMed

    Mocanu, Carmen; Mocanu, Mihai

    2007-01-01

    The paper presents the initial efforts of description and implementation for a new scheme of electronic patients recording, based on distributed database for chronic ophthalmologic diseases. Structural specifications derived from principal system's goals are the implementation of an efficient and flexible way of patients' data administration, using actual Web technologies, permitting future extensions, without reducing in performances and without exponential cost increasing. A very important aspect, that must be take into consideration is their interfacing with other medical programs and systems, as the systems for recording clinical data, monitoring systems (Patient Administrations Systems - PAS) for demographical data, systems for monitoring of treatment (Hippocrates program), web systems, including wireless.

  7. The Use of Electronic Medical Records

    PubMed Central

    Makoul, Gregory; Curry, Raymond H.; Tang, Paul C.

    2001-01-01

    Objective: To assess physician–patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. Design: An exploratory, observational study involving analysis of videotaped physician–patient encounters, questionnaires, and medical-record reviews. Setting: General internal medicine practice at an academic medical center. Participants: Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). Main Outcome Measures: Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. Results: Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patient's agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patient's life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. Summary: An EMR system may enhance the ability of physicians to complete informationintensive tasks but

  8. Lead User Design: Medication Management in Electronic Medical Records.

    PubMed

    Price, Morgan; Weber, Jens H; Davies, Iryna; Bellwood, Paule

    2015-01-01

    Improvements in medication management may lead to a reduction of preventable errors. Usability and user experience issues are common and related to achieving benefits of Electronic Medical Records (EMRs). This paper reports on a novel study that combines the lead user method with a safety engineering review to discover an innovative design for the medication management module in EMRs in primary care. Eight lead users were recruited that represented prescribers and clinical pharmacists with expertise in EMR design, evidence-based medicine, medication safety and medication research. Eight separate medication management module designs were prototyped and validated, one with each lead user. A parallel safety review of medicaiton management was completed. The findings were synthesized into a single common set of goals, activities and one interactive, visual prototype. The lead user method with safety review proved to be an effective way to elicit diverse user goals and synthesize them into a common design. The resulting design ideas focus on meeting the goals of quality, efficiency, safety, reducing the cognitive load on the user, and improving communication wih the patient and the care team. Design ideas are being adapted to an existing EMR product, providing areas for further work.

  9. 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...

  10. 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 upon...

  11. 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 medical...

  12. 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 medical...

  13. 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. ... 12 Banks and Banking 4 2011-01-01 2011-01-01 false Special procedures: Medical records....

  14. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ...: 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 medical...

  15. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ...: 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 medical...

  16. 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...

  17. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 3 2010-01-01 2010-01-01 false Special procedures for medical records. 261a.7... Requests by Individual to Whom Record Pertains § 261a.7 Special procedures for medical records. Medical or psychological records requested pursuant to § 261a.5 of this part shall be disclosed directly to the...

  18. 5 CFR 297.205 - Access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 1 2010-01-01 2010-01-01 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...

  19. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 4 2010-07-01 2010-07-01 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...

  20. 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 be...

  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 determines...

  2. 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 determines...

  3. 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 of...

  4. 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 special...

  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 be...

  6. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 5 2013-10-01 2013-10-01 false Condition: Medical records. 494.170 Section 494.170... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and...: Completion of patient records and centralization of clinical information. (1) Current medical records and...

  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 of...

  8. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 5 2014-10-01 2014-10-01 false Condition: Medical records. 494.170 Section 494.170... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and...: Completion of patient records and centralization of clinical information. (1) Current medical records and...

  9. 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 special...

  10. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 5 2011-10-01 2011-10-01 false Condition: Medical records. 494.170 Section 494.170... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and...: Completion of patient records and centralization of clinical information. (1) Current medical records and...

  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 requesting...

  12. 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 of...

  13. 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 be...

  14. The computerized medical record in action.

    PubMed

    Meyer, C R

    1994-08-01

    Before the advent of the IPS computerized medical record at Burlington, Zallen did not own a computer. Although he learned touch-typing in high school, he emphatically states that he hated it. The average age of the physicians on staff at Burlington is about 40, but few had extensive previous experience with computers. According to Zallen, all have adapted to the CPR with few tears or tirades. The physicians continue to "tweak" the system to customize their own scrapbook and templates. Lahey physicians who work at Burlington part time are using the system, although with more staff help. The CPR is alive and well at Burlington Health Center. HCHP physicians can and do use computers in their daily work, producing quality medical records that are readable and retrievable. Nonetheless, promises that computers will make records more complete and accessible and will improve quality measurement will be mere blather if the CPR doesn't make users' lives easier. My last question to Zallen was "How has this system made your life harder?" After one pensive second, he replied, "I really can't think of anything." To me, that is potent testimony that the CPR is not a techie's fantasy, but rather, a pragmatic, workable answer to the needs of 21st century medicine.

  15. Mining free-text medical records.

    PubMed

    Heinze, D T; Morsch, M L; Holbrook, J

    2001-01-01

    Text mining projects can be characterized along four parameters: 1) the demands of the market in terms of target domain and specificity and depth of queries; 2) the volume and quality of text in the target domain; 3) the text mining process requirements; and 4) the quality assurance process that validates the extracted data. In this paper, we provide lessons learned and results from a large-scale commercial project using Natural Language Processing (NLP) for mining the transcriptions of dictated clinical records in a variety of medical specialties. We conclude that the current state-of-the-art in NLP is suitable for mining information of moderate content depth across a diverse collection of medical settings and specialties.

  16. Computerization of medical and exposure records.

    PubMed

    Rossi, D A; Cox, J D; Seger, M J

    1982-06-01

    An interdisciplinary team of occupational health professionals and computer engineers at Digital Equipment Corporation have developed a computerized system for maintaining employee medical and exposure records. The Industrial Health Monitoring System (IHMS) was designed to meet the occupational and public health needs of employees engaged in semiconductor manufacturing operations where exposure to potentially hazardous chemicals and physical agents exists. The purpose of the IHMS is to systematically retrieve and analyze data collected from industrial hygiene, health services, and clinical diagnostic testing in order to monitor the general health of the working community.

  17. Personal health records as portal to the electronic medical record.

    PubMed

    Cahill, Jennifer E; Gilbert, Mark R; Armstrong, Terri S

    2014-03-01

    This topic review discusses the evolving clinical challenges associated with the implementation of electronic personal health records (PHR) that are fully integrated with electronic medical records (EMR). The benefits of facilitating patient access to the EMR through web-based, PHR-portals may be substantial; foremost is the potential to enhance the flow of information between patient and healthcare practitioner. The benefits of improved communication and transparency of care are presumed to be a reduction in clinical errors, increased quality of care, better patient-management of disease, and better disease and symptom comprehension. Yet PHR databases allow patients open access to newly-acquired clinical data without the benefit of concurrent expert clinical interpretation, and therefore may create the potential for greater patient distress and uncertainty. With specific attention to neuro-oncology patients, this review focuses on the developing conflicts and consequences associated with the use of a PHR that parallels data acquisition of the EMR in real-time. We conclude with a discussion of recommendations for implementing fully-integrated PHR for neuro-oncology patients.

  18. 11 CFR 1.6 - Special procedure: Medical records. [Reserved

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 11 Federal Elections 1 2010-01-01 2010-01-01 false Special procedure: Medical records. 1.6 Section 1.6 Federal Elections FEDERAL ELECTION COMMISSION PRIVACY ACT § 1.6 Special procedure: Medical records....

  19. Shallow medication extraction from hospital patient records.

    PubMed

    Boytcheva, Svetla

    2011-01-01

    This paper presents methods for shallow Information Extraction (IE) from the free text zones of hospital Patient Records (PRs) in Bulgarian language in the Patient Safety through Intelligent Procedures in medication (PSIP) project. We extract automatically information about drug names, dosage, modes and frequency and assign the corresponding ATC code to each medication event. Using various modules for rule-based text analysis, our IE components in PSIP perform a significant amount of symbolic computations. We try to address negative statements, elliptical constructions, typical conjunctive phrases, and simple inferences concerning temporal constraints and finally aim at the assignment of the drug ACT code to the extracted medication events, which additionally complicates the extraction algorithm. The prototype of the system was used for experiments with a training corpus containing 1,300 PRs and the evaluation results are obtained using a test corpus containing 6,200 PRs. The extraction accuracy (f-score) for drug names is 98.42% and for dose 93.85%.

  20. 5 CFR 2504.6 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Special procedures for medical records... PRESIDENT PRIVACY ACT REGULATIONS § 2504.6 Special procedures for medical records. (a) When the Privacy Act Officer receives a request from an individual for access to those official medical records which belong...

  1. 12 CFR 1403.6 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 7 2010-01-01 2010-01-01 false Special procedures for medical records. 1403.6 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...

  2. 49 CFR 386.48 - Medical records and physicians' reports.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 5 2010-10-01 2010-10-01 false Medical records and physicians' reports. 386.48... HAZARDOUS MATERIALS PROCEEDINGS General Rules and Hearings § 386.48 Medical records and physicians' reports... results, and other medical records that a party intends to rely upon shall be served on all other...

  3. 12 CFR 603.325 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Special procedures for medical records. 603.325 Section 603.325 Banks and Banking FARM CREDIT ADMINISTRATION ADMINISTRATIVE PROVISIONS PRIVACY ACT REGULATIONS § 603.325 Special procedures for medical records. Medical records in the custody of the...

  4. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 4 2010-07-01 2010-07-01 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...

  5. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 1 2014-01-01 2014-01-01 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...

  6. 38 CFR 46.6 - Medical quality assurance records confidentiality.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 2 2010-07-01 2010-07-01 false Medical quality assurance records confidentiality. 46.6 Section 46.6 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS... Medical quality assurance records confidentiality. Note that medical quality assurance records that...

  7. 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 which...

  8. 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 the...

  9. 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 the...

  10. 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 requester...

  11. 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 which...

  12. 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 the...

  13. 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 of...

  14. 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 requester...

  15. 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 the...

  16. 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 which...

  17. Medical record search engines, using pseudonymised patient identity: an alternative to centralised medical records.

    PubMed

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

    2011-02-01

    The purpose of our multidisciplinary study was to define a pragmatic and secure alternative to the creation of a national centralised medical record which could gather together the different parts of the medical record of a patient scattered in the different hospitals where he was hospitalised without any risk of breaching confidentiality. We first analyse the reasons for the failure and the dangers of centralisation (i.e. difficulty to define a European patients' identifier, to reach a common standard for the contents of the medical record, for data protection) and then propose an alternative that uses the existing available data on the basis that setting up a safe though imperfect system could be better than continuing a quest for a mythical perfect information system that we have still not found after a search that has lasted two decades. We describe the functioning of Medical Record Search Engines (MRSEs), using pseudonymisation of patients' identity. The MRSE will be able to retrieve and to provide upon an MD's request all the available information concerning a patient who has been hospitalised in different hospitals without ever having access to the patient's identity. The drawback of this system is that the medical practitioner then has to read all of the information and to create his own synthesis and eventually to reject extra data. Faced with the difficulties and the risks of setting up a centralised medical record system, a system that gathers all of the available information concerning a patient could be of great interest. This low-cost pragmatic alternative which could be developed quickly should be taken into consideration by health authorities. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

  18. 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…

  19. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 21 Food and Drugs 8 2013-04-01 2013-04-01 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...

  20. 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... magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  1. 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 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...

  2. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 21 Food and Drugs 8 2012-04-01 2012-04-01 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...

  3. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data...

  4. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data...

  5. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data...

  6. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data...

  7. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data...

  8. Electronic medical records and the gastroenterologist.

    PubMed

    Kosinski, Lawrence R

    2012-01-01

    This is an age of disruptive innovation in health care in which the business model is changing. Fee-for-service, volume-based systems are being replaced by fixed-fee, value-based systems. One of the major facilitating forces behind this change has been the development of the electronic health record, which is providing the medical community with the ability to have real-time quality metrics that will drive the development of web-based clinical decision support tools that will transform the current peer-review-based rules of practice with an eclectic fluid environment of continuous quality measurement and improvement. Copyright © 2012 Elsevier Inc. All rights reserved.

  9. Progress in electronic medical record adoption in Canada.

    PubMed

    2015-12-01

    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 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. 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. 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. 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.

  10. 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

  11. Anonymization of Longitudinal Electronic Medical Records

    PubMed Central

    Tamersoy, Acar; Loukides, Grigorios; Nergiz, Mehmet Ercan; Saygin, Yucel; Malin, Bradley

    2013-01-01

    Electronic medical record (EMR) systems have enabled healthcare providers to collect detailed patient information from the primary care domain. At the same time, longitudinal data from EMRs are increasingly combined with biorepositories to generate personalized clinical decision support protocols. Emerging policies encourage investigators to disseminate such data in a deidentified form for reuse and collaboration, but organizations are hesitant to do so because they fear such actions will jeopardize patient privacy. In particular, there are concerns that residual demographic and clinical features could be exploited for reidentification purposes. Various approaches have been developed to anonymize clinical data, but they neglect temporal information and are, thus, insufficient for emerging biomedical research paradigms. This paper proposes a novel approach to share patient-specific longitudinal data that offers robust privacy guarantees, while preserving data utility for many biomedical investigations. Our approach aggregates temporal and diagnostic information using heuristics inspired from sequence alignment and clustering methods. We demonstrate that the proposed approach can generate anonymized data that permit effective biomedical analysis using several patient cohorts derived from the EMR system of the Vanderbilt University Medical Center. PMID:22287248

  12. Recorded interviews with human and medical geneticists.

    PubMed

    Harper, Peter S

    2017-02-01

    A series of 100 recorded interviews with human and medical geneticists has been carried out and some general results are reported here. Twenty countries across the world are represented, mostly European, with a particular emphasis on the United Kingdom. A priority was given to older workers, many of whom were key founders of human genetics in their own countries and areas of work, and over 20 of whom are now no longer living. The interviews also give valuable information on the previous generation of workers, as teachers and mentors of the interviewees, thus extending the coverage of human genetics back to the 1930s or even earlier. A number of prominent themes emerge from the interview series; notably the beginnings of human cytogenetics from the late 1950s, the development of medical genetics research and its clinical applications in the 1960s and 1970s, and more recently the beginnings and rapid growth of human molecular genetics. The interviews provide vivid personal portraits of those involved, and also show the effects of social and political issues, notably those arising from World War 2 and its aftermath, which affected not only the individuals involved but also broader developments in human genetics, such as research related to risks of irradiation. While this series has made a start in the oral history of this important field, extension and further development of the work is urgently needed to give a fuller picture of how human genetics has developed.

  13. Medication adherence, medical record accuracy, and medication exposure in real-world patients using comprehensive medication monitoring.

    PubMed

    Ryan, Timothy P; Morrison, Ryan D; Sutherland, Jeffrey J; Milne, Stephen B; Ryan, Kendall A; Daniels, J Scott; Misra-Hebert, Anita; Hicks, J Kevin; Vogan, Eric; Teng, Kathryn; Daly, Thomas M

    2017-01-01

    Poor adherence to medication regimens and medical record inconsistencies result in incomplete knowledge of medication therapy in polypharmacy patients. By quantitatively identifying medications in the blood of patients and reconciling detected medications with the medical record, we have defined the severity of this knowledge gap and created a path toward optimizing medication therapy. We validated a liquid chromatography-tandem mass spectrometry assay to detect and/or quantify 38 medications across a broad range of chronic diseases to obtain a comprehensive survey of patient adherence, medical record accuracy, and exposure variability in two patient populations. In a retrospectively tested 821-patient cohort representing U.S. adults, we found that 46% of medications assessed were detected in patients as prescribed in the medical record. Of the remaining medications, 23% were detected, but not listed in the medical record while 30% were prescribed to patients, but not detected in blood. To determine how often each detected medication fell within literature-derived reference ranges when taken as prescribed, we prospectively enrolled a cohort of 151 treatment-regimen adherent patients. In this cohort, we found that 53% of medications that were taken as prescribed, as determined using patient self-reporting, were not within the blood reference range. Of the medications not in range, 83% were below and 17% above the lower and upper range limits, respectively. Only 32% of out-of-range medications could be attributed to short oral half-lives, leaving extensive exposure variability to result from patient behavior, undefined drug interactions, genetics, and other characteristics that can affect medication exposure. This is the first study to assess compliance, medical record accuracy, and exposure as determinants of real-world treatment and response. Variation in medication detection and exposure is greater than previously demonstrated, illustrating the scope of current

  14. 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 medical...

  15. 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 medical...

  16. 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 special...

  17. 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 special...

  18. 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 medical...

  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. 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... instrument used to make the survey, and the name of the individual who performed the survey....

  1. 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

  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. Installing and Implementing a Computer-based Patient Record System in Sub-Saharan Africa: The Mosoriot Medical Record System

    PubMed Central

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

    2003-01-01

    The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data are recorded on a paper encounter form, eliminating duplicate documentation in multiple clinic logbooks. Data are entered into an MS-Access database supported by redundant power systems. The system was initiated in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After system implementation, patient visits were 22% shorter. They spent 58% less time with providers (p < 0.001) and 38% less time waiting (p = 0.06). Clinic personnel spent 50% less time interacting with patients, two thirds less time interacting with each other, and more time in personal activities. This simple electronic medical record system has bridged the “digital divide.” Financial and technical sustainability by Kenyans will be key to its future use and development. PMID:12668697

  4. Electronic Health Records: VAs Efforts Raise Concerns about Interoperability Goals and Measures, Duplication with DOD, and Future Plans

    DTIC Science & Technology

    2016-07-13

    modernize their systems were duplicative and recommended that their decisions should be justified by comparing the costs and schedules of alternate ...integrated system that would be used by both departments. Table 1 summarizes a number of these key initiatives. Table 1: History of the Departments of...systems were duplicative and stressed that their decisions should be justified by comparing the costs and schedules of alternate approaches.13 We

  5. Market factors and electronic medical record adoption in medical practices.

    PubMed

    Menachemi, Nir; Mazurenko, Olena; Kazley, Abby Swanson; Diana, Mark L; Ford, Eric W

    2012-01-01

    Previous studies identified individual or practice factors that influence practice-based physicians' electronic medical record (EMR) adoption. Less is known about the market factors that influence physicians' EMR adoption. The aim of this study was to explore the relationship between environmental market characteristics and physicians' EMR adoption. The Health Tracking Physician Survey 2008 and Area Resource File (2008) were combined and analyzed. Binary logistic regression was used to examine the relationship between three dimensions of the market environment (munificence, dynamism, and complexity) and EMR adoption controlling for several physician and practice characteristics. In a nationally representative sample of 4,720 physicians, measures of market dynamism including increases in unemployment, odds ratio (OR) = 0.95, 95% confidence interval (CI) [0.91, 0.99], or poverty rates, OR = 0.93, 95% CI [0.89, 0.96], were negatively associated with EMR adoption. Health maintenance organization penetration, OR = 3.01, 95% CI [1.49, 6.05], another measure of dynamism, was positively associated with EMR adoption. Physicians practicing in areas with a malpractice crisis, OR = 0.82, 95% CI [0.71, 0.94], representing environmental complexity, had lower EMR adoption rates. Understanding how market factors relate to practice-based physicians' EMR adoption can assist policymakers to better target limited resources as they work to realize the national goal of universal EMR adoption and meaningful use.

  6. Privacy Impact Assessment for the Wellness Program Medical Records

    EPA Pesticide Factsheets

    The Wellness Program Medical Records System collects contact information and other Personally Identifiable Information (PII). Learn how this data is collected, used, accessed, the purpose of data collection, and record retention policies.

  7. The Importance of the Medical Record: A Critical Professional Responsibility.

    PubMed

    Ngo, Elizabeth; Patel, Nachiket; Chandrasekaran, Krishnaswamy; Tajik, A Jamil; Paterick, Timothy E

    2016-01-01

    Comprehensive, detailed documentation in the medical record is critical to patient care and to a physician when allegations of negligence arise. Physicians, therefore, would be prudent to have a clear understanding of this documentation. It is important to understand who is responsible for documentation, what is important to document, when to document, and how to document. Additionally, it should be understood who owns the medical record, the significance of the transition to the electronic medical record, problems and pitfalls when using the electronic medical record, and how the Health Information Technology for Economic and Clinical Health Act affects healthcare providers and health information technology.

  8. Implementation of an Electronic Medical Records System

    DTIC Science & Technology

    2008-05-07

    their patients and their previous medical history. Capitalizing on progress made in the informational technology realm, which include more...example, medication and allergy list, problem list and past medical and family/ social history); • Building the descriptive tags for a lab or radiology...clinical trials. Arch Fam Med. 1996; 5: 271-278. 14. Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: systematic review of

  9. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 18 Conservation of Power and Water Resources 2 2012-04-01 2012-04-01 false Special procedures-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...

  10. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 18 Conservation of Power and Water Resources 2 2013-04-01 2012-04-01 true Special procedures-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...

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

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 18 Conservation of Power and Water Resources 2 2014-04-01 2014-04-01 false Special procedures-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...

  12. 18 CFR 1301.16 - Special procedures-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 procedures-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...

  13. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... maintained by the Commission which pertain to him or her, medical and psychological records merit special treatment because of the possibility that disclosure will have an adverse physical or psychological effect... medical and/or psychological records which pertain to him or her, he or she shall, in his or her...

  14. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... maintained by the Commission which pertain to him or her, medical and psychological records merit special treatment because of the possibility that disclosure will have an adverse physical or psychological effect... medical and/or psychological records which pertain to him or her, he or she shall, in his or her...

  15. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... maintained by the Commission which pertain to him or her, medical and psychological records merit special treatment because of the possibility that disclosure will have an adverse physical or psychological effect... medical and/or psychological records which pertain to him or her, he or she shall, in his or her...

  16. 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…

  17. 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…

  18. Privacy Act System of Records: Medical and Research Study Records of Human Volunteers, EPA-34

    EPA Pesticide Factsheets

    Learn about the Medical and Research Study Records of Human Volunteers System, including who is covered in the system, the purpose of data collection, routine uses for the system's records, and other security procedures.

  19. [Audit: medical record documentation among advanced cancer patients].

    PubMed

    Perceau, Elise; Chirac, Anne; Rhondali, Wadih; Ruer, Murielle; Chabloz, Claire; Filbet, Marilène

    2014-02-01

    Medical record documentation of cancer inpatients is a core component of continuity of care. The main goal of the study was an assessment of medical record documentation in a palliative care unit (PCU) using a targeted clinical audit based on deceased inpatients' charts. Stage 1 (2010): a clinical audit of medical record documentation assessed by a list of items (diagnosis, prognosis, treatment, power of attorney directive, advance directives). Stage 2 (2011): corrective measures. Stage 3 (2012): re-assessment with the same items' list after six month. Forty cases were investigated during stage 1 and 3. After the corrective measures, inpatient's medical record documentation was significantly improved, including for diagnosis (P = 0.01), diseases extension and treatment (P < 0.001). Our results highlighted the persistence of a weak rate of medical record documentation for advanced directives (P = 0.145).

  20. Computerized medical records: defining a standard without the computer.

    PubMed

    Bradbury, A R

    1991-01-01

    The inevitable computerization of medical records may be a boon or a hindrance to the practice of medicine. A comprehensive view of the project is essential for its success. Definite goals for the computerized medical record are stated to this end. An argument is presented for keeping the structure of the medical record separate from any specific requirements of technology. An elegant structure for medical records is proposed, independent of any computer system and requiring a minimum of definitions or special characters. The roles of clinical specialists (such as physicians and nurses), medical records specialists, administrators, accountants, and computer architects (hardware and software) are defined. In particular, the tasks of lexicon and template creation are defined and emphasized as urgent and ongoing challenges for specialty organizations.

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

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... doctor or other person to act as his agent as described in § 701.310(a). Records containing medical or... request. (b) If the individual has not named a medical doctor as agent, the Council may determine, after consultation with a medical doctor, that disclosure of the information would have an adverse effect on...

  2. Electronic health records and online medical records: an asset or a liability under current conditions?

    PubMed

    Allen-Graham, Judith; Mitchell, Lauren; Heriot, Natalie; Armani, Roksana; Langton, David; Levinson, Michele; Young, Alan; Smith, Julian A; Kotsimbos, Tom; Wilson, John W

    2017-01-20

    Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information.Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital's current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary.Results Of all medical records audited, 82% contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49% of records audited showed evidence the discharge summary was sent outside the institution.Conclusions The quality of medical data captured and information management is variable across hospitals. It is recommended that medical history documentation guidelines and standardised discharge summaries be implemented in Australian healthcare services.What is known about this topic? Australia has a complex health system, the government has approved funding to develop a universal online electronic medical record system and is currently trialling this in an opt-out style in the Napean Blue Mountains (NSW) and in Northern Queensland. The system was originally named the personally controlled electronic health record but has since been changed to MyHealth Record (2016). In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This

  3. The electronic medical record system: health care marvel or morass?

    PubMed

    Silverman, D C

    1998-01-01

    The author considers the potential advantages and disadvantages, as well as possible unintended consequences, of introducing electronic medical record systems in health care organizations. Special consideration is given to the issues such information systems raise concerning privacy, confidentiality, and quality of care from both patient and provider perspectives. The potential gains from computerizing medical records include the benefit of instantaneous availability of patients' medical history, treatment regimes, and current health status in routine and emergency clinical situations. Ease of access to this information should reduce adverse outcomes. The added value of a complete and up-to-date medical record immediately available to medical caregivers seems undeniable. The potential disadvantages include issues around patient confidentiality and unauthorized access to records, the enormous capital investment for computer hardware, and system maintenance.

  4. [Accessing medical records for research purposes].

    PubMed

    Alcalde Bezhold, Guillermo; Alfonso Farnós, Iciar

    2013-01-01

    The Organic Law 15/1999 of 13 December on the Protection of Personal Data and the Law 41/2002 of 14 November regulating patient autonomy and rights and obligations of information and clinical documentation are the basic rules which govern the medical history in Spain. However, the lack of development of these laws regarding data protection in clinical research, particularly in terms of access to the medical history, repeatedly causes doubts about its construction by the Research Ethics Committees. Therefore, the aim of this paper is to analyze the rules which govern the access to the medical history for research purposes, with particular emphasis on the common problems that arise in the Committees for the ethical evaluation of these projects and finally setting a series of recommendations. The use for research purpose of genetic personal data contained in the medical history is also addressed in this paper. In this sense, a key contribution of the Law on Biomedical Research is relating to the specific regulation of the genetic personal data, both with respect to their production and access to the data as a support and regarding to its use for research purpose.

  5. Improving medical record retrieval for validation studies in Medicare data.

    PubMed

    Wright, Nicole C; Delzell, Elizabeth S; Smith, Wilson K; Xue, Fei; Auroa, Tarun; Curtis, Jeffrey R

    2017-04-01

    The purpose of the study is to describe medical record retrieval for a study validating claims-based algorithms used to identify seven adverse events of special interest (AESI) in a Medicare population. We analyzed 2010-2011 Medicare claims of women with postmenopausal osteoporosis and men ≥65 years of age in the Medicare 5% national sample. The final cohorts included beneficiaries covered continuously for 12+ months by Medicare parts A, B, and D and not enrolled in Medicare Advantage before starting follow-up. We identified beneficiaries using each AESI algorithm and randomly selected 400 women and 100 men with each AESI for medical record retrieval. The Centers for Medicare and Medicaid Services provided beneficiary contact information, and we requested medical records directly from providers, without patient contact. We selected 3331 beneficiaries (women: 2272; men: 559) for whom we requested 3625 medical records. Overall, we received 1738 [47.9% (95%CI 46.3%, 49.6%)] of the requested medical records. We observed small differences in the characteristics of the total population with AESIs compared with those randomly selected for retrieval; however, no differences were seen between those selected and those retrieved. We retrieved 54.7% of records requested from hospitals compared with 26.3% of records requested from physician offices (p < 0.001). Retrieval did not differ by sex or vital status of the beneficiaries. Our national medical record validation study of claims-based algorithms produced a modest retrieval rate. The medical record procedures outlined in this paper could have led to the improved retrieval from our previous medical record retrieval study. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  6. [A practicable model of a secure electronic medical record system].

    PubMed

    Zhu, Yuan-zhong; Zhong, Le-Haiz

    2006-09-01

    In this article, a new application model has been given for digital signing technology used in the Electronic Medical Record system, which uses digital signature to implement authentication mechanism and doctor signing, and uses a notarial digital signature server to implement the third party's digital signature for notarial mechanism. It can prevent the others from modifying the doctor's record and prevent the doctor himself from modifying the record as well. Case history database preserves signed data to ensure the authenticity and validity, in law, of the Electronic Medical Record.

  7. Design elements of a telemedical medical record.

    PubMed Central

    Adelhard, K.; Eckel, R.; Hölzel, D.; Tretter, W.

    1996-01-01

    Computerized Patient Records are becoming telemedical and multimedia documents. They should accompany the patients their whole lifetime and collect data from many different sites. Special requirements are arising to fulfill these demands. A prototype of such a system was designed and implemented at the university hospital in Grosshadern, Germany to show its feasibility, discuss the design elements and demonstrate its capabilities. A Flexible data model, interpretable contents, open communication structures and physical compilation are the cornerstones of this approach that allows communication via Internet or Smart cards. PMID:8947711

  8. Data base management, feedback control, and the Regenstrief Medical Record.

    PubMed

    McDonald, C; Blevins, L; Glazener, T; Haas, J; Lemmon, L; Meeks-Johnson, J

    1983-04-01

    Because of the differences in informational needs among medical practices, medical record systems should be flexible. The use of data base management and use-oriented command languages helps to achieve flexibility. The Regenstrief Medical Record System is based upon a data base management system and two user-oriented command languages (the RDB Command Language and CARE). Most batch reports, file maintenance procedures, and ad hoc retrievals can be specified by the user by means of these two languages. This means that the user can specify which reports he wants and how they should look. Daily on-line activities are performed by application programs. The data base system also provides flexibility to these programs since the content and format of many of the display screens are defined by statements that are similar to the command language statements and are stored within a text file. The Regenstrief Medical Record System now carries records for 60,000 patients.

  9. Interior, middle wing, medical records storage. Notice roof trusses. ...

    Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

    Interior, middle wing, medical records storage. Notice roof trusses. - Fitzsimons General Hospital, Nurses' Mess & Kitchen, Nurses' Recreation, West McAfee Avenue, North of Building 507, Aurora, Adams County, CO

  10. 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.

  11. 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.

  12. [Information extraction methodology used in electronic medical records].

    PubMed

    Chen, Yingying; Ye, Feng

    2011-01-01

    We try to use information extraction technology in some parts of the medical records and extract disease information to accumulate experience for extracting complete information from medical records. This paper attempts to use dictionary and rules to achieve the named entity recognition. Information extraction is based on shallow parsing and use pattern sentence matching method with the help of a 3 levels finite state automaton.

  13. 44 CFR 6.31 - Special requirements for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... and probable outcome, the system manager shall not release the medical information to the subject... 44 Emergency Management and Assistance 1 2010-10-01 2010-10-01 false Special requirements for medical records. 6.31 Section 6.31 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT...

  14. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 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 and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose...

  15. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 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 and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose...

  16. The electronic patient records of the Hannover Medical School.

    PubMed

    Porth, A J; Niehoff, C; Matthies, H K

    1999-01-01

    In this paper, the successful introduction of a commercially available electronic patient record archiving system at the Hannover Medical School is described. Since 1996, more than 11 million document sheets of 130,000 patient records have been stored electronically. Currently, 100,000 sheets are stored each week.

  17. 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...

  18. 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...

  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, 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...

  1. 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...

  2. 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.

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

    PubMed

    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.

  4. 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

  5. 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.

  6. Atigeo at TREC 2012 Medical Records Track: ICD-9 Code Description Injection to Enhance Electronic Medical Record Search Accuracy

    DTIC Science & Technology

    2012-11-01

    codes that represent the diagnoses and procedures described in those medical records. We have developed a suite of natural language processing (NLP...to promote the research and development of free-text search engines that can find electronic medical records (EMRs or reports) that are relevant to...test and refine the natural language processing (NLP) components we have developed to support our xPatterns Computer-Aided Coding (CAC) product

  7. 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

    ... Public Property NATIONAL ARCHIVES AND RECORDS ADMINISTRATION RECORDS MANAGEMENT MICROFORMS RECORDS MANAGEMENT Microfilming Standards § 1238.16 What are the microfilming requirements for temporary records.... Agencies may select a film stock that meets their needs and ensures the preservation of the microforms...

  8. 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,…

  9. $\\mathtt {Deepr}$: A Convolutional Net for Medical Records.

    PubMed

    Nguyen, Phuoc; Tran, Truyen; Wickramasinghe, Nilmini; Venkatesh, Svetha

    2017-01-01

    Feature engineering remains a major bottleneck when creating predictive systems from electronic medical records. At present, an important missing element is detecting predictive regular clinical motifs from irregular episodic records. We present Deepr (short for Deep record), a new end-to-end deep learning system that learns to extract features from medical records and predicts future risk automatically. Deepr transforms a record into a sequence of discrete elements separated by coded time gaps and hospital transfers. On top of the sequence is a convolutional neural net that detects and combines predictive local clinical motifs to stratify the risk. Deepr permits transparent inspection and visualization of its inner working. We validate Deepr on hospital data to predict unplanned readmission after discharge. Deepr achieves superior accuracy compared to traditional techniques, detects meaningful clinical motifs, and uncovers the underlying structure of the disease and intervention space.

  10. Moving electronic medical records upstream: incorporating social determinants of health.

    PubMed

    Gottlieb, Laura M; Tirozzi, Karen J; Manchanda, Rishi; Burns, Abby R; Sandel, Megan T

    2015-02-01

    Knowledge of the biological pathways and mechanisms connecting social factors with health has increased exponentially over the past 25 years, yet in most clinical settings, screening and intervention around social determinants of health are not part of standard clinical care. Electronic medical records provide new opportunities for assessing and managing social needs in clinical settings, particularly those serving vulnerable populations. To illustrate the feasibility of capturing information and promoting interventions related to social determinants of health in electronic medical records. Three case studies were examined in which electronic medical records have been used to collect data and address social determinants of health in clinical settings. From these case studies, we identified multiple functions that electronic medical records can perform to facilitate the integration of social determinants of health into clinical systems, including screening, triaging, referring, tracking, and data sharing. If barriers related to incentives, training, and privacy can be overcome, electronic medical record systems can improve the integration of social determinants of health into healthcare delivery systems. More evidence is needed to evaluate the impact of such integration on health care outcomes before widespread adoption can be recommended. Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

  11. Medical education in the electronic medical record (EMR) era: benefits, challenges, and future directions.

    PubMed

    Tierney, Michael J; Pageler, Natalie M; Kahana, Madelyn; Pantaleoni, Julie L; Longhurst, Christopher A

    2013-06-01

    In the last decade, electronic medical record (EMR) use in academic medical centers has increased. Although many have lauded the clinical and operational benefits of EMRs, few have considered the effect these systems have on medical education. The authors review what has been documented about the effect of EMR use on medical learners through the lens of the Accreditation Council for Graduate Medical Education's six core competencies for medical education. They examine acknowledged benefits and educational risks to use of EMRs, consider factors that promote their successful use when implemented in academic environments, and identify areas of future research and optimization of EMRs' role in medical education.

  12. A Mis-recognized Medical Vocabulary Correction System for Speech-based Electronic Medical Record

    PubMed Central

    Seo, Hwa Jeong; Kim, Ju Han; Sakabe, Nagamasa

    2002-01-01

    Speech recognition as an input tool for electronic medical record (EMR) enables efficient data entry at the point of care. However, the recognition accuracy for medical vocabulary is much poorer than that for doctor-patient dialogue. We developed a mis-recognized medical vocabulary correction system based on syllable-by-syllable comparison of speech text against medical vocabulary database. Using specialty medical vocabulary, the algorithm detects and corrects mis-recognized medical vocabularies in narrative text. Our preliminary evaluation showed 94% of accuracy in mis-recognized medical vocabulary correction.

  13. Concordance between medical records and interview data in correctional facilities

    PubMed Central

    2014-01-01

    Background Self- administered questionnaires or interviews and medical records are often used as sources of research data; thus it is essential to evaluate their concordance and reliability. The aim of this paper was to assess the concordance between medical and behavioral data obtained from medical records and interview questionnaires in two correctional facilities. Methods Medical record and interview data were compared for 679 inmates from one male and one female maximum security prison between April 2010 and February 2013. Gender non-stratified and gender-stratified analyses were conducted in SPSS to calculate the prevalence and kappa coefficient scores (κ) for medical (e.g., HIV, diabetes, hypertension) and behavioral (e.g., smoking, drug use, tattoos) conditions. Sensitivity/specificity between medical records and interview were calculated in the gender non-stratified data. Results In the gender non-stratified analysis, κ score for HIV, hepatitis C, diabetes, asthma, and history of tattoos had strong or good concordance (0.66-0.89). Hypertension, renal/kidney disease, cigarette smoking, antibiotic use in the last 6 months, and cocaine use ever were moderately correlated (0.49-0.57). Both history of any illicit drug use ever (0.36) and marijuana use ever (0.23) had poor concordance. Females had higher κ scores and prevalence rates than males overall. Medical conditions were reported more frequently in medical records and behavioral conditions had higher prevalence in interviews. Sensitivity for medical conditions in the combined facility data ranged from 50.0% to 86.0% and 48.2% to 85.3% for behavioral conditions whereas specificity ranged from 95.9% to 99.5% for medical conditions and 75.9% to 92.8% for behavioral conditions. Conclusion Levels of agreement between medical records and self-reports varied by type of factor. Medical conditions were more frequently reported by chart review and behavioral factors more frequently by self-report. Data source

  14. Duplicated laboratory tests: evaluation of a computerized alert intervention abstract.

    PubMed

    Bridges, Sharon A; Papa, Linda; Norris, Anne E; Chase, Susan K

    2014-01-01

    Redundant testing contributes to reductions in healthcare system efficiency. The purpose of this study was to: (1) determine if the use of a computerized alert would reduce the number and cost of duplicated Acute Hepatitis Profile (AHP) laboratory tests and (2) assess what patient, test, and system factors were associated with duplication. This study used a quasi-experimental pre- and post-test design to determine the proportion of duplication of the AHP test before and after implementation of a computerized alert intervention. The AHP test was duplicated if the test was requested again within 15 days of the initial test being performed and the result present in the medical record. The intervention consisted of a computerized alert (pop-up window) that indicated to the clinician that the test had recently been ordered. A total of 674 AHP tests were performed in the pre-intervention period and 692 in the postintervention group. In the pre-intervention period, 53 (7.9%) were duplicated and in postintervention, 18 (2.6%) were duplicated (p<.001). The implementation of the alert was shown to significantly reduce associated costs of duplicated AHP tests (p≤.001). Implementation of computerized alerts may be useful in reducing duplicate laboratory tests and improving healthcare system efficiency. © 2012 National Association for Healthcare Quality.

  15. Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study.

    PubMed

    Perry, Jeffrey J; Sutherland, Jane; Symington, Cheryl; Dorland, Katie; Mansour, Marlene; Stiell, Ian G

    2014-12-01

    Electronic medical records are becoming an integral part of healthcare delivery. The goal of this study was to compare paper documentation versus electronic medical record for non-traumatic chest pain to determine differences in time for physicians to complete medical records using paper versus electronic mediums. We also assessed physician satisfaction with the electronic format. We conducted this before-after study in a single large tertiary care academic emergency department. In the 'Before Period', stopwatches determined the time for paper medical recording. In the 'After Period', a template-based electronic medical record was introduced and the time for electronic recording was measured. The time to record in the before and after periods were compared using a two-sided t test. We surveyed physicians to assess satisfaction. We enrolled 100 non-traumatic patients with chest pain in the before period and 73 in the after period. The documentation time was longer using electronic charting, (9.6±5.9 min vs 6.1±2.5 min; p<0.001). 18 of 20 physicians participating in the after period completed surveys. Physicians were not satisfied with the electronic patient recording for non-traumatic chest pain. This is the first study that we are aware of which compared paper versus electronic medical records in the emergency department. Electronic recording took longer than paper records. Physicians were not satisfied using this electronic record. Given the time pressures on emergency physicians, a solution to minimise the charting time using electronic medical records must be found before widespread uptake of electronic charting will be possible. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  16. 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…

  17. 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…

  18. 28 CFR 79.5 - Requirements for medical documentation, contemporaneous records, and other records or documents.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Requirements for medical documentation, contemporaneous records, and other records or documents. 79.5 Section 79.5 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CLAIMS UNDER THE RADIATION EXPOSURE COMPENSATION ACT General § 79.5 Requirements...

  19. 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.

  20. Considering Governance for Patient Access to E-Medical Records.

    PubMed

    Day, Karen; Wells, Susan

    2015-01-01

    People having access to their medical records could have a transformative improvement effect on healthcare delivery and use. Our research aimed to explore the concerns and attitudes of giving people electronic access to their medical records through patient portals. We conducted 28 semi-structured interviews with 30 people, asking questions about portal design, organisational implications and governance. We report the findings of the governance considerations raised during the interviews. These revealed that (1) there is uncertainty about the possible design and extent of giving people access to their medical records to view/use, (2) existing policies about patient authentication, proxy, and privacy require modification, and (3) existing governance structures and functions require further examination and adjustment. Future research should include more input from patients and health informaticians.

  1. CRFs based de-identification of medical records

    PubMed Central

    He, Bin; Guan, Yi; Cheng, Jianyi; Cen, Keting; Hua, Wenlan

    2016-01-01

    De-identification is a shared task of the 2014 i2b2/UTHealth challenge. The purpose of this task is to remove protected health information (PHI) from medical records. In this paper, we propose a novel de-identifier, WI-deId, based on conditional random fields (CRFs). A preprocessing module, which tokenizes the medical records using regular expressions and an off-the-shelf tokenizer, is introduced, and three groups of features are extracted to train the de-identifier model. The experiment shows that our system is effective in the de-identification of medical records, achieving a micro-F1 of 0.9232 at the i2b2 strict entity evaluation level. PMID:26315662

  2. 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.

  3. 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. © 2013 Wiley Publishing Asia Pty Ltd.

  4. A model for critiquing based on automated medical records.

    PubMed

    van der Lei, J; Musen, M A

    1991-08-01

    We describe the design of a critiquing system, HyperCritic, that relies on automated medical records for its data input. The purpose of the system is to advise general practitioners who are treating patients who have hypertension. HyperCritic has access to the data stored in a primary-care information system that supports a fully automated medical record. Hyper-Critic relies on data in the automated medical record to critique the management of hypertensive patients, avoiding a consultation-style interaction with the user. The first step in the critiquing process involves the interpretation of the medical record in an attempt to discover the physician's actions and decisions. After detecting the relevant events in the medical record, HyperCritic views the task of critiquing as the assignment of critiquing statements to these patient-specific events. Critiquing statements are defined as recommendations involving one or more suggestions for possible modifications in the actions of the physician. The core of the model underlying HyperCritic is that the process of generating the critiquing statements is viewed as the application of a limited set of abstract critiquing tasks. We distinguish four categories of critiquing tasks: preparation tasks, selection tasks, monitoring tasks, and responding tasks. The execution of these critiquing tasks requires specific medical factual knowledge. This factual knowledge is separated from the critiquing tasks and is stored in a medical fact base. The principal advantage demonstrated by HyperCritic is the adaption of a domain-independent critiquing structure. We show how this domain-independent critiquing structure can be used to facilitate knowledge acquisition and maintenance of the system.

  5. Customer-oriented medical records can promote patient satisfaction.

    PubMed

    MacStravic, R S

    1988-04-01

    The customer-oriented medical record helps promote patient satisfaction by providing a mechanism to monitor and document quality of care from the patient's perspective. Information that should be contained in the record includes the following: Personal and family information. Reasons for selecting the provider. Reasons for patient visit. Patient requests and responses thereto. Provider and staff observations. Patient feedback. Summaries of previous visits. Record of progress made. In addition to promoting patient satisfaction, the customer-oriented medical record provides a data base for analyzing the current market that can be used in designing marketing communications to attract new patients. It also contributes to provider success by reminding care givers of their commitment to patient satisfaction, motivating them to be sensitive to patients' needs and expectations, and helping them to personalize the care experience.

  6. A hypermedia-based medical records management system.

    PubMed

    Laforest, F; Frénot, S; Flory, A

    1998-01-01

    This article presents a new way to manage computerized medical records, based on a totally-hypermedia system. As a matter of fact, the classical use of a database limits the necessary variability of the medical record, in function of both the patient profile and the care practitioner habits. The system we propose is based on a hospital Intranet, and on the XML language. This language allows the definition of semantic tags in hyperdocuments, and thus information retrieval is ensured through semantic tags indexation.

  7. Improving medical records filing in a municipal hospital in Ghana.

    PubMed

    Teviu, E A A; Aikins, M; Abdulai, T I; Sackey, S; Boni, P; Afari, E; Wurapa, F

    2012-09-01

    Medical records are kept in the interest of both the patient and clinician. Proper filing of patient's medical records ensures easy retrieval and contributes to decreased patient waiting time at the hospital and continuity of care. This paper reports on an intervention study to address the issue of misfiling and multiple patient folders in a health facility. Intervention study. Municipal Hospital, Goaso, Asunafo North District, Brong Ahafo Region, Ghana. Methods employed for data collection were records review, direct observation and tracking of folders. Interventions instituted were staff durbars, advocacy and communication, consultations, in-service trainings, procurement and monitoring. Factors contributing to issuance of multiple folders and misfiling were determined. Proportion of multiple folders was estimated. Results revealed direct and indirect factors contributing to issuance of multiple patient folders and misfiling. Interventions and monitoring reduce acquisition of numerous medical folders per patient and misfiling. After the intervention, there was significant reduction in the use of multiple folders (i.e., overall 97% reduction) and a high usage of single patient medical folders (i.e., 99%). In conclusion, a defined medical records filing system with adequate training, logistics and regular monitoring and supervision minimises issuance of multiple folders and misfiling.

  8. [Three new records of medical plant in Hubei, China].

    PubMed

    Li, Hou-Cong; Yuan, De-Pei; Liu, Yuan

    2014-07-01

    In order to have a better understanding of the species diversity of medical plants in Enshi, Hubei of China, extensive field investigations and specimen collections were conducted in Enshi and adjacent regions. Based on field observations of plants in their living habitats and comparative morphological studies on specimens in herbarium of Hubei minzu University and other available herbaria as well, three new records of medical plants in Hubei, Scutellaria yunnanensis, Alangium faberi var. heterophyllum, and Drymaria diandra, were reported in this paper.

  9. 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.

  10. A literature review of medical record keeping by foreign medical teams in sudden onset disasters.

    PubMed

    Jafar, Anisa J N; Norton, Ian; Lecky, Fiona; Redmond, Anthony D

    2015-04-01

    Medical records are a tenet of good medical practice and provide one method of communicating individual follow-up arrangements, informing research data, and documenting medical intervention. The objective of this review was to look at one source (the published literature) of medical records used by foreign medical teams (FMTs) in sudden onset disasters (SODs). The published literature was searched systematically for evidence of what medical records have been used by FMTs in SODs. Findings The style and content of medical records kept by FMTs in SODs varied widely according to the published literature. Similarly, there was great variability in practice as to what happens to the record and/or the data from the record following its use during a patient encounter. However, there was a paucity of published work comprehensively detailing the exact content of records used. Interpretation Without standardization of the content of medical records kept by FMTs in SODs, it is difficult to ensure robust follow-up arrangements are documented. This may hinder communication between different FMTs and local medical teams (LMTs)/other FMTs who may then need to provide follow-up care for an individual. Furthermore, without a standard method of reporting data, there is an inaccurate picture of the work carried out. Therefore, there is not a solid evidence base for improving the quality of future response to SODs. Further research targeting FMTs and LMTs directly is essential to inform any development of an internationally agreed minimum data set (MDS), for both recording and reporting, in order that FMTs can reach the World Health Organization (WHO) standards for FMT practice.

  11. [Security specifications for electronic medical records on the Internet].

    PubMed

    Mocanu, Mihai; Mocanu, Carmen

    2007-01-01

    The extension for the Web applications of the Electronic Medical Record seems both interesting and promising. Correlated with the expansion of Internet in our country, it allows the interconnection of physicians of different specialties and their collaboration for better treatment of patients. In this respect, the ophthalmologic medical applications consider the increased possibilities for monitoring chronic ocular diseases and for the identification of some elements for early diagnosis and risk factors supervision. We emphasize in this survey some possible solutions to the problems of interconnecting medical information systems to the Internet: the achievement of interoperability within medical organizations through the use of open standards, the automated input and processing for ocular imaging, the use of data reduction techniques in order to increase the speed of image retrieval in large databases, and, last but not least, the resolution of security and confidentiality problems in medical databases.

  12. Patient access to medical records on a psychiatric inpatient unit.

    PubMed

    Stein, E J; Furedy, R L; Simonton, M J; Neuffer, C H

    1979-03-01

    The authors studied the effects of patient access to medical records during hospitalization in a psychiatric unit of a community general hospital. Questionnaires were completed by about 20 staff and 88 patients, and records were compared with those from an earlier period to note any changes in the written record. Patients reported feeling better informed and more involved in their treatment, and staff said that they became more thoughtful about their notes in the chart. The availability of staff seems crucial to this process and facilitates the working alliance.

  13. 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:...

  14. 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:...

  15. An Analysis of the Medical Records Clerking Occupation.

    ERIC Educational Resources Information Center

    Ridener, Norma A.; And Others

    The general purpose of the occupational analysis is to provide workable, basic information dealing with the many and varied duties performed in the medical records clerk occupation. The document opens with a brief introduction followed by a job description. The bulk of the document is presented in table form. Nine duties are broken down into a…

  16. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 12 Banks and Banking 3 2011-01-01 2011-01-01 false Special procedures for medical records. 261a.7 Section 261a.7 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM RULES REGARDING ACCESS TO PERSONAL INFORMATION UNDER THE PRIVACY ACT 1974 Procedures for...

  17. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 12 Banks and Banking 4 2013-01-01 2013-01-01 false Special procedures for medical records. 261a.7 Section 261a.7 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM (CONTINUED) RULES REGARDING ACCESS TO PERSONAL INFORMATION UNDER THE PRIVACY ACT 1974...

  18. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 4 2012-01-01 2012-01-01 false Special procedures for medical records. 261a.7 Section 261a.7 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM (CONTINUED) RULES REGARDING ACCESS TO PERSONAL INFORMATION UNDER THE PRIVACY ACT 1974...

  19. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 12 Banks and Banking 4 2014-01-01 2014-01-01 false Special procedures for medical records. 261a.7 Section 261a.7 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM (CONTINUED) RULES REGARDING ACCESS TO PERSONAL INFORMATION UNDER THE PRIVACY ACT 1974...

  20. 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

  1. 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…

  2. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... from the individual the name and address of the individual's physician and/or psychologist; (3) Seek... psychologist, if the Department believes such consultation is advisable; (4) Seek written consent from the individual for the Department to provide the medical records to the individual's physician or...

  3. 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…

  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. 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:...

  7. Data-driven approach for creating synthetic electronic medical records.

    PubMed

    Buczak, Anna L; Babin, Steven; Moniz, Linda

    2010-10-14

    New algorithms for disease outbreak detection are being developed to take advantage of full electronic medical records (EMRs) that contain a wealth of patient information. However, due to privacy concerns, even anonymized EMRs cannot be shared among researchers, resulting in great difficulty in comparing the effectiveness of these algorithms. To bridge the gap between novel bio-surveillance algorithms operating on full EMRs and the lack of non-identifiable EMR data, a method for generating complete and synthetic EMRs was developed. This paper describes a novel methodology for generating complete synthetic EMRs both for an outbreak illness of interest (tularemia) and for background records. The method developed has three major steps: 1) synthetic patient identity and basic information generation; 2) identification of care patterns that the synthetic patients would receive based on the information present in real EMR data for similar health problems; 3) adaptation of these care patterns to the synthetic patient population. We generated EMRs, including visit records, clinical activity, laboratory orders/results and radiology orders/results for 203 synthetic tularemia outbreak patients. Validation of the records by a medical expert revealed problems in 19% of the records; these were subsequently corrected. We also generated background EMRs for over 3000 patients in the 4-11 yr age group. Validation of those records by a medical expert revealed problems in fewer than 3% of these background patient EMRs and the errors were subsequently rectified. A data-driven method was developed for generating fully synthetic EMRs. The method is general and can be applied to any data set that has similar data elements (such as laboratory and radiology orders and results, clinical activity, prescription orders). The pilot synthetic outbreak records were for tularemia but our approach may be adapted to other infectious diseases. The pilot synthetic background records were in the 4

  8. Discrepancies between medical record data and parent reported use of preventive asthma medications.

    PubMed

    Gutiérrez, Susana J; Fagnano, Maria; Wiesenthal, Elise; Koehler, Alana D; Halterman, Jill S

    2014-05-01

    To assess whether medical record documentation reflects actual home practices regarding the administration of preventive medications to urban children with persistent asthma. Baseline data from a prompting asthma intervention were used for this cross-sectional analysis. As part of the larger study, we enrolled children (2-12 years) with persistent asthma in the waiting room at 12 primary care offices (2009-2012). Prior to their visit with a healthcare provider, caregivers reported information regarding their child's asthma symptom severity and current preventive medications (i.e. name and frequency of use). We compared caregiver-reported medication information with medical record data to determine the rate of complete concordance, defined as total consistency between the prescribed medication data documented in the medical record and parent report describing how the child is actually using the medication at home. According to 310 completed medical record reviews, 194 (62%) children had a current prescription for a daily preventive asthma medication. Of these children, 110 (57%) had caregivers who reported complete concordance. Those reporting complete concordance were more likely to have children with greater symptom severity, including fewer symptom-free days in the prior two weeks (6.9 vs. 8.7, p = 0. 018), and ≥1 asthma-related hospitalization in the prior year (16% vs. 6%, p = 0. 042). Medical records may poorly reflect actual home practices and providers should specifically inquire about medication use and barriers to adherence at the time of an office visit to promote guideline-based, consistent treatment for children with persistent asthma.

  9. Medical record keeping and system performance in orthopaedic trauma patients.

    PubMed

    Cosic, Filip; Kimmel, Lara; Edwards, Elton

    2016-02-18

    Objective The medical record is critical for documentation and communication between healthcare professionals. The aim of the present study was to evaluate important aspects of the orthopaedic medical record and system performance to determine whether any deficiencies exist in these areas.Methods Review of 200 medical records of surgically treated traumatic lower limb injury patients was undertaken. The operative report, discharge summary and first and second outpatient reviews were evaluated.Results In all cases, an operative report was completed by a senior surgeon. Weight-bearing status was adequately documented in 91% of reports. Discharge summaries were completed for 82.5% of admissions, with 87.3% of these having instructions reflective of those in the operative report. Of first and second outpatient reviews, 69% and 73%, respectively, occurred within 1 week of the requested time. Previously documented management plans were changed in 30% of reviews. At 6-months post-operatively, 42% of patients had been reviewed by a member of their operating team.Discussion Orthopaedic medical record documentation remains an area for improvement. In addition, hospital out-patient systems perform suboptimally and may affect patient outcomes.What is known about the topic? Medical records are an essential tool in modern medical practice. Despite the importance of comprehensive documentation in the medical record, numerous examples of poor documentation have been demonstrated, including substandard documentation during consultant ward rounds by junior doctors leading to a breakdown in healthcare professional communication and potential patient mismanagement. Further inadequacies of medical record documentation have been demonstrated in surgical discharge notes, with complete and correct documentation reported to be as low as 65%.What does this paper add? Standards of patient care should be constantly monitored and deficiencies identified in order to implement a remedy and close

  10. Image-based document management systems for medical records.

    PubMed

    Massengill, S P

    1992-03-01

    Using image scanning as a document capture mechanism at time of treatment or on day of discharge automates the medical record to achieve the larger objectives of simultaneous concurrent access to an electronic chart. This form of keyless document capture, although appearing labor intensive, is justified for improving business management and quality of care. Coupled with optical character recognition or barcode recognition for keyless data capture, medical information may be more easily made available for clinical research. Not merely a microfilm alternative, a medical record management system accelerates chart completion. Labor reduction is realized by eliminating filing and retrieval of active charts, loose sheet handling, photocopying, chart assembly, and chart location control. By reducing the reasons for chart completion delays, accelerated billing of Medicare accounts will occur, resulting in a reduction in receivables. Image-based document management systems accomplish the three things required of a senior manager in health care: (1) solve problems, (2) save money, and (3) make money.

  11. 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.

  12. Implementation of standardized nomenclature in the electronic medical record.

    PubMed

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

    2009-01-01

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

  13. 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....

  14. Secure scalable disaster electronic medical record and tracking system.

    PubMed

    Demers, Gerard; Kahn, Christopher; Johansson, Per; Buono, Colleen; Chipara, Octav; Griswold, William; Chan, Theodore

    2013-10-01

    Electronic medical records (EMRs) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass-casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability. Report As the prehospital disaster EMR allows for more robust content including protected health information (PHI), security measures must be instituted to safeguard these data. The Wireless Internet Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld, linked, wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. This system has been field tested in a number of exercises with excellent results, and future iterations will incorporate robust security measures. A secure prehospital triage EMR improves documentation quality during disaster drills.

  15. Semantic Relations for Problem-Oriented Medical Records

    PubMed Central

    Uzuner, Ozlem; Mailoa, Jonathan; Ryan, Russell; Sibanda, Tawanda

    2010-01-01

    Summary Objective We describe semantic relation (SR) classification on medical discharge summaries. We focus on relations targeted to the creation of problem-oriented records. Thus, we define relations that involve the medical problems of patients. Methods and Materials We represent patients’ medical problems with their diseases and symptoms. We study the relations of patients’ problems with each other and with concepts that are identified as tests and treatments. We present an SR classifier that studies a corpus of patient records one sentence at a time. For all pairs of concepts that appear in a sentence, this SR classifier determines the relations between them. In doing so, the SR classifier takes advantage of surface, lexical, and syntactic features and uses these features as input to a support vector machine. We apply our SR classifier to two sets of medical discharge summaries, one obtained from the Beth Israel-Deaconess Medical Center (BIDMC), Boston, MA and the other from Partners Healthcare, Boston, MA. Results On the BIDMC corpus, our SR classifier achieves micro-averaged F-measures that range from 74% to 95% on the various relation types. On the Partners corpus, the micro-averaged F-measures on the various relation types range from 68% to 91%. Our experiments show that lexical features (in particular, tokens that occur between candidate concepts, which we refer to as inter-concept tokens) are very informative for relation classification in medical discharge summaries. Using only the inter-concept tokens in the corpus, our SR classifier can recognize 84% of the relations in the BIDMC corpus and 72% of the relations in the Partners corpus. Conclusion These results are promising for semantic indexing of medical records. They imply that we can take advantage of lexical patterns in discharge summaries for relation classification at a sentence level. PMID:20646918

  16. Medical Record Clerk Training Program, Course of Study; Instructor's Guide: 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.

    A program of education including training materials is presented to improve the technical proficiency of medical record clerks in small, rural hospitals. The program is planned for fifteen days of instruction or approximately 120 hours including evaluation, orientation and discussion sessions. Students are expected to have a high school diploma…

  17. MEDICAL RECORD TECHNOLOGY, A COURSE OF STUDY DESIGNED FOR COOPERATIVE PART-TIME STUDENTS EMPLOYED IN MEDICAL RECORD LIBRARIES.

    ERIC Educational Resources Information Center

    KARNES, JAMES B.

    DESIGNED FOR USE BY ELEVENTH GRADE COOPERATIVE PART-TIME STUDENTS EMPLOYED IN MEDICAL RECORD LIBRARIES, THIS GUIDE MAY ALSO BE USED IN AREA VOCATIONAL OR POST-HIGH SCHOOL SETTINGS. IT WAS DEVELOPED BY A CONSULTANT COMMITTEE, TEACHER EDUCATORS, AND RESEARCH ASSISTANTS AT THE STATE LEVEL AND REVISED AFTER USE IN THE FIELD. THE CONTENT OBJECTIVES ARE…

  18. 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

  19. PAMFOnline: integrating EHealth with an electronic medical record system.

    PubMed

    Tang, Paul C; Black, William; Buchanan, Jenny; Young, Charles Y; Hooper, David; Lane, Steven R; Love, Barbara; Mitchell, Charlotte; Smith, Nancy; Turnbull, Jenifer R

    2003-01-01

    The Institute of Medicine stressed the need for continuous healing relationships, yet the delivery of health care has traditionally been confined to the physician office or hospital. We implemented an eHealth application tightly integrated with our electronic medical record system that provides patients with a convenient, continuously available communication channel to their physician's office. Patients can view summary data from their medical record, including the results of diagnostic tests, and request medical advice, prescription renewals, appointments, or updates to their demographic information. We have found that patients embrace this new communication channel and are using the service appropriately. Patients especially value electronic messaging with their physicians and timely access to their test results. While initially concerned about an increase in work, physicians have found that use of electronic messaging can be an efficient method for handling non-urgent communication with their patients. Online tools for patients, when integrated with an electronic medical record, can provide patients with better access to health information, improve patient satisfaction, and improve operational efficiency.

  20. 41 CFR 105-64.208 - What special conditions apply to release of medical records?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... apply to release of medical records? 105-64.208 Section 105-64.208 Public Contracts and Property....208 What special conditions apply to release of medical records? Medical records containing... writing by you, or by your guardian or conservator. Medical records in an Official Personnel Folder...

  1. 20 CFR 30.700 - What kinds of medical records must providers keep?

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 20 Employees' Benefits 1 2010-04-01 2010-04-01 false What kinds of medical records must providers... for Medical Providers Medical Records and Bills § 30.700 What kinds of medical records must providers keep? Federal Government medical officers, private physicians and hospitals are required to...

  2. 20 CFR 10.800 - What kind of medical records must providers keep?

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 20 Employees' Benefits 1 2010-04-01 2010-04-01 false What kind of medical records must providers...' COMPENSATION ACT, AS AMENDED Information for Medical Providers Medical Records and Bills § 10.800 What kind of medical records must providers keep? Agency medical officers, private physicians and hospitals...

  3. Prevalence of Sharing Access Credentials in Electronic Medical Records.

    PubMed

    Hassidim, Ayal; Korach, Tzfania; Shreberk-Hassidim, Rony; Thomaidou, Elena; Uzefovsky, Florina; Ayal, Shahar; Ariely, Dan

    2017-07-01

    Confidentiality of health information is an important aspect of the physician patient relationship. The use of digital medical records has made data much more accessible. To prevent data leakage, many countries have created regulations regarding medical data accessibility. These regulations require a unique user ID for each medical staff member, and this must be protected by a password, which should be kept undisclosed by all means. We performed a four-question Google Forms-based survey of medical staff. In the survey, each participant was asked if he/she ever obtained the password of another medical staff member. Then, we asked how many times such an episode occurred and the reason for it. A total of 299 surveys were gathered. The responses showed that 220 (73.6%) participants reported that they had obtained the password of another medical staff member. Only 171 (57.2%) estimated how many time it happened, with an average estimation of 4.75 episodes. All the residents that took part in the study (45, 15%) had obtained the password of another medical staff member, while only 57.5% (38/66) of the nurses reported this. The use of unique user IDs and passwords to defend the privacy of medical data is a common requirement in medical organizations. Unfortunately, the use of passwords is doomed because medical staff members share their passwords with one another. Strict regulations requiring each staff member to have it's a unique user ID might lead to password sharing and to a decrease in data safety.

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

    PubMed

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

    2011-03-22

    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. 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. 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. A system that gathers all of the currently available

  5. Integrating all medical records to an enterprise viewer.

    PubMed

    Li, Haomin; Duan, Huilong; Lu, Xudong; Zhao, Chenhui; An, Jiye

    2005-01-01

    The idea behind hospital information systems is to make all of a patient's medical reports, lab results, and images electronically available to clinicians, instantaneously, wherever they are. But the higgledy-piggledy evolution of most hospital computer systems makes it hard to integrate all these clinical records. Although several integration standards had been proposed to meet this challenger, none of them is fit to Chinese hospitals. In this paper, we introduce our work of implementing a three-tiered architecture enterprise viewer in Huzhou Central Hospital to integration all existing medical information systems using limited resource.

  6. 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.

  7. Using Organizational Development for Electronic Medical Record Transformation.

    PubMed

    Kiel, Joan M

    With mandates requiring the transition from paper medical records to the use of electronic medical records, organizations are embarking on a change process. To engender this process, organizational development models and interventions based predominantly on the theories of Chris Argyris, Warren Bennis, and the team of Paul Lawrence and Jay Lorsch are explored. Interventions are subdivided into behavioral and structural as organizations benefit by recognizing a need for change and, perhaps, a cultural shift in addition to refocusing their mission. To support these interventions, a champion or super user is recommended to maintain the momentum of the transformation and enculturation. With so many changes in the internal and external environments, organizations must respond systematically for, in health care, lives depend on it.

  8. 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.

  9. Medical record review conduction model for improving interrater reliability of abstracting medical-related information.

    PubMed

    Engel, Lisa; Henderson, Courtney; Fergenbaum, Jennifer; Colantonio, Angela

    2009-09-01

    Medical record review (MRR) is often used in clinical research and evaluation, yet there is limited literature regarding best practices in conducting a MRR, and there are few studies reporting interrater reliability (IRR) from MRR data. The aim of this research was twofold: (a) to develop a MRR abstraction tool and standardize the MRR process and (b) to examine the IRR from MRR data. This study introduces the MRR-Conduction Model, which was used to implement a MRR, and examines the IRR between two abstractors who collected preinjury medical and psychiatric, incident-related medical and postinjury head symptom information from the medical records of 47 neurologically injured workers. Results showed that the percentage agreement was > or =85% and the unweighted kappa statistic was > or =.60 for most variables, indicating substantial IRR. An effective and reliable MRR to abstract medical-related information requires planning and time. The MRR-Conduction Model is proposed to guide the process of creating a MRR.

  10. Profile-based Retrieval of Records in Medical Databases

    PubMed Central

    Kementsietsidis, Anastasios; Lim, Lipyeow; Wang, Min

    2009-01-01

    Ontologies establish relationships between different terms, yet their potential in querying has not yet been fully realized. In this paper, we study the problem of ontology-supported profile-based retrieval of medical records. We present an algorithm that provides two independent techniques (used in isolation or in unison) to address the shortcomings of existing keyword-based retrieval solutions, and provide an implementation and experiments to illustrate the merits of our approach. PMID:20351871

  11. Library instruction within the medical record administration curriculum.

    PubMed Central

    Marcotte, J M; Graves, K J

    1981-01-01

    A course for medical record administration (MRA) students has been developed at the University of Tennessee Center for the Health Sciences Library. The course's objectives are: (1) to train students in the use of the resources and services of health sciences libraries and (2) to provide basic instruction in the organization, operation, and management of a small hospital library. These objectives are met by integrating library use instruction within the MRA curriculum and by presenting a five-week hospital library management workshop. Library use instruction includes a library orientation and sessions on the use of major reference sources, writing for publication, and the use and evaluation of the medical record literature. The workshop covers the role of the medical record administrator as manager of the hospital library. Sessions cover basic principles of hospital library administration, technical and public services, and sources of outside assistance. Results are reported of a survey of graduates conducted to determine whether a need for the course still existed and if the changes made as a result of the evaluation process were appropriate. The teaching methods and evaluation techniques used in this course are applicable to library instruction in other disciplines. PMID:7225659

  12. 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.

  13. Diffusion of Electronic Medical Record Based Public Hospital Information Systems.

    PubMed

    Cho, Kyoung Won; Kim, Seong Min; An, Chang-Ho; Chae, Young Moon

    2015-07-01

    This study was conducted to evaluate the adoption behavior of a newly developed Electronic Medical Record (EMR)-based information system (IS) at three public hospitals in Korea with a focus on doctors and nurses. User satisfaction scores from four performance layers were analyzed before and two times after the newly develop system was introduced to evaluate the adoption process of the IS with Rogers' diffusion theory. The 'intention to use' scores, the most important indicator for determining whether or not to adopt the IS in Rogers' confirmation stage for doctors, were very high in the third survey (4.21). In addition, the scores for 'reduced medication errors', which is the key indicator for evaluating the success of the IS, increased in the third survey for both doctors and nurses. The factors influencing 'intention to use' with a high odds ratio (>1.5) were the 'frequency of attendance of user training sessions', 'mandatory use of system', 'reduced medication errors', and 'reduced medical record documentation time' for both doctors and nurses. These findings show that the new EMR-based IS was well accepted by doctors. Both doctors and nurses also positively considered the effects of the new IS on their clinical environments.

  14. Visualization index for image-enabled medical records

    NASA Astrophysics Data System (ADS)

    Dong, Wenjie; Zheng, Weilin; Sun, Jianyong; Zhang, Jianguo

    2011-03-01

    With the widely use of healthcare information technology in hospitals, the patients' medical records are more and more complex. To transform the text- or image-based medical information into easily understandable and acceptable form for human, we designed and developed an innovation indexing method which can be used to assign an anatomical 3D structure object to every patient visually to store indexes of the patients' basic information, historical examined image information and RIS report information. When a doctor wants to review patient historical records, he or she can first load the anatomical structure object and the view the 3D index of this object using a digital human model tool kit. This prototype system helps doctors to easily and visually obtain the complete historical healthcare status of patients, including large amounts of medical data, and quickly locate detailed information, including both reports and images, from medical information systems. In this way, doctors can save time that may be better used to understand information, obtain a more comprehensive understanding of their patients' situations, and provide better healthcare services to patients.

  15. 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.

  16. Structure, importance and recording of therapeutic information in the medical record: a multicentre observational study.

    PubMed

    Tichelaar, Jelle; van Unen, Robert J; Brinkman, David J; Fluitman, Pieter H M; van Agtmael, Michiel A; de Vries, Theo P G M; Richir, Milan C

    2015-12-01

    Structuring the diagnostic section of the medical record (MR) improves diagnosis and communication between doctors. However, little is known about the therapeutic section of the MR. The aim of this study was to gain insight into the extent to which MRs are structured for therapeutic information, to determine which therapeutic data registrars and clinical consultants consider should be recorded in the MR and to what extent registrars record this information themselves. A multicentre observational study was carried out in the internal medicine outpatient clinics of five teaching hospitals in the Netherlands. Preformatted structure, importance and actual recording of therapeutic information was compared with a reference list of 35 therapeutic items based on the WHO Guide to Good Prescribing (e.g. drug name, indication for drug). The preformatted structure of four paper MRs and one electronic MR was assessed. Eight of the 35 therapeutic items were listed in the paper MRs and 18 items in the electronic MR. Registrars and consultants agreed on the importance of recording most of the therapeutic items in the MR, 25 and 27 out of the 35 items, respectively; however, registrars recorded only 11 of the 35 items in the paper MR and 20 of the 35 items in the electronic MR. The structure and content of paper and electronic MRs are not adequate. While both registrars and consultants agree on the importance of recording therapeutic items in the MR, registrars fail to record most of this information in practice. The results of this study can be used as starting point for the discussion regarding the necessity of structured recording of therapeutic information in the MR and its possible benefits with regard to medication safety and training of the new generation of prescribers. © 2015 John Wiley & Sons, Ltd.

  17. Data-driven approach for creating synthetic electronic medical records

    PubMed Central

    2010-01-01

    Background New algorithms for disease outbreak detection are being developed to take advantage of full electronic medical records (EMRs) that contain a wealth of patient information. However, due to privacy concerns, even anonymized EMRs cannot be shared among researchers, resulting in great difficulty in comparing the effectiveness of these algorithms. To bridge the gap between novel bio-surveillance algorithms operating on full EMRs and the lack of non-identifiable EMR data, a method for generating complete and synthetic EMRs was developed. Methods This paper describes a novel methodology for generating complete synthetic EMRs both for an outbreak illness of interest (tularemia) and for background records. The method developed has three major steps: 1) synthetic patient identity and basic information generation; 2) identification of care patterns that the synthetic patients would receive based on the information present in real EMR data for similar health problems; 3) adaptation of these care patterns to the synthetic patient population. Results We generated EMRs, including visit records, clinical activity, laboratory orders/results and radiology orders/results for 203 synthetic tularemia outbreak patients. Validation of the records by a medical expert revealed problems in 19% of the records; these were subsequently corrected. We also generated background EMRs for over 3000 patients in the 4-11 yr age group. Validation of those records by a medical expert revealed problems in fewer than 3% of these background patient EMRs and the errors were subsequently rectified. Conclusions A data-driven method was developed for generating fully synthetic EMRs. The method is general and can be applied to any data set that has similar data elements (such as laboratory and radiology orders and results, clinical activity, prescription orders). The pilot synthetic outbreak records were for tularemia but our approach may be adapted to other infectious diseases. The pilot synthetic

  18. Giving patients a copy of their computer medical record.

    PubMed

    Sheldon, M G

    1982-02-01

    Medical summaries were prepared by a general practitioner for inclusion in a computer system. Both the medical records and a patient-filled questionnaire were used. A representative sample of the practice population were then sent their summaries. In creating the summaries the general practitioner felt the need to exclude 11 diagnoses whenever they appeared (5 per cent of the patients), and to suppress one or more diagnoses in a further 14 per cent of patients. In 2 per cent of summaries the general practitioner felt unable to give a copy to the patient because he was afraid of an adverse reaction by the patient or immediate relatives.The patients' views of the usefulness of the summaries, and of their accuracy and completeness, were sought by a questionnaire. Replies were received from 71 per cent; of these, 91 per cent reported that they thought the summary useful. However, in 18 per cent of cases, the patients requested additions, corrections or deletions. Only 1 per cent of patients replied that they definitely did not like the idea of a computer containing their medical information.Some of the benefits and difficulties both of using a computer to store medical information, and of giving the patient a copy of the medical summary, are discussed.

  19. 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

  20. Automated de-identification of free-text medical records.

    PubMed

    Neamatullah, Ishna; Douglass, Margaret M; Lehman, Li-wei H; Reisner, Andrew; Villarroel, Mauricio; Long, William J; Szolovits, Peter; Moody, George B; Mark, Roger G; Clifford, Gari D

    2008-07-24

    Text-based patient medical records are a vital resource in medical research. In order to preserve patient confidentiality, however, the U.S. Health Insurance Portability and Accountability Act (HIPAA) requires that protected health information (PHI) be removed from medical records before they can be disseminated. Manual de-identification of large medical record databases is prohibitively expensive, time-consuming and prone to error, necessitating automatic methods for large-scale, automated de-identification. We describe an automated Perl-based de-identification software package that is generally usable on most free-text medical records, e.g., nursing notes, discharge summaries, X-ray reports, etc. The software uses lexical look-up tables, regular expressions, and simple heuristics to locate both HIPAA PHI, and an extended PHI set that includes doctors' names and years of dates. To develop the de-identification approach, we assembled a gold standard corpus of re-identified nursing notes with real PHI replaced by realistic surrogate information. This corpus consists of 2,434 nursing notes containing 334,000 words and a total of 1,779 instances of PHI taken from 163 randomly selected patient records. This gold standard corpus was used to refine the algorithm and measure its sensitivity. To test the algorithm on data not used in its development, we constructed a second test corpus of 1,836 nursing notes containing 296,400 words. The algorithm's false negative rate was evaluated using this test corpus. Performance evaluation of the de-identification software on the development corpus yielded an overall recall of 0.967, precision value of 0.749, and fallout value of approximately 0.002. On the test corpus, a total of 90 instances of false negatives were found, or 27 per 100,000 word count, with an estimated recall of 0.943. Only one full date and one age over 89 were missed. No patient names were missed in either corpus. We have developed a pattern-matching de

  1. 32 CFR 806b.17 - Special provision for certain medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 6 2010-07-01 2010-07-01 false Special provision for certain medical records... ADMINISTRATION PRIVACY ACT PROGRAM Giving Access to Privacy Act Records § 806b.17 Special provision for certain medical records. If a physician believes that disclosing requested medical records could harm the...

  2. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 6 2010-07-01 2010-07-01 false Disclosing the medical records of minors. 806b... ADMINISTRATION PRIVACY ACT PROGRAM Disclosing Records to Third Parties § 806b.48 Disclosing the medical records of minors. Air Force personnel may disclose the medical records of minors to their parents or...

  3. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Access to medical and psychological records. 324... DEFENSE (CONTINUED) PRIVACY PROGRAM DFAS PRIVACY ACT PROGRAM Individual Access to Records § 324.13 Access to medical and psychological records. Individual access to medical and psychological records...

  4. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 2 2013-07-01 2013-07-01 false Access to medical and psychological records. 324... to medical and psychological records. Individual access to medical and psychological records should... be asked to provide the name of a personal physician, and the record will be provided to that...

  5. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 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 should... be asked to provide the name of a personal physician, and the record will be provided to that...

  6. Healthcare delivery for women in prison: a medical record review.

    PubMed

    Abbott, Penelope; Magin, Parker; Hu, Wendy

    2016-05-09

    When women come into prison, many have unmet health needs. In this study we examine the health care provided to women in prison and their identified health needs, and discuss opportunities for improved healthcare delivery. We undertook a medical record review of women released from a minimum 6-week period of incarceration in New South Wales correctional centres between May 2013 and January 2014. Records from 231 periods of incarceration were reviewed. At reception, 52% of women were identified as having anxiety or depression. Hearing health was not documented despite 30% of records being of women from an Aboriginal and Torres Strait Islander background, a high-risk group for whom hearing screening is recommended. Most women had multiple in-prison clinical contacts, including interactions with general and specialised nurses (97%), general practitioners (65%) and psychiatrists (35%). At release, 49% were on psychotropic medication and most required ongoing management for: mental health (71%), substance misuse (65%) and physical health (61%) problems. External specialist appointments were pending in 7% at release. Health management plans generated in prison were not always completed before release for reasons including custodial factors and waits for hospital-based appointments. Provision of effective health care in prison requires improved integration with community health services, including timely access to a wide range of health services while women are in prison, and continuity of care at release.

  7. Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers.

    PubMed

    Wittels, Kathleen; Wallenstein, Joshua; Patwari, Rahul; Patel, Sundip

    2017-01-01

    Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships. We performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted. We received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%). Close to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student documentation indicating the importance for

  8. Accuracy of Electronic Medical Record Medication Reconciliation in Emergency Department Patients.

    PubMed

    Monte, Andrew A; Anderson, Peter; Hoppe, Jason A; Weinshilboum, Richard M; Vasiliou, Vasilis; Heard, Kennon J

    2015-07-01

    Medication history discrepancies have the potential to cause significant adverse clinical effects for patients. More than 40% of medication errors can be traced to inadequate reconciliation. The objective of this study was to determine the accuracy of electronic medical record (EMR)-reconciled medication lists obtained in an academic emergency department (ED). Comprehensive research medication ingestion histories for the 48 h preceding ED visit were performed and compared to reconciled EMR medication lists in a convenience sample of ED patients. The reconciled EMR list of prescription, nonprescription, vitamins, herbals, and supplement medications were compared against a structured research medication history tool. We measured the accuracy of the reconciled EMR list vs. the research history for all classes of medications as the primary outcome. Five hundred and two subjects were enrolled. The overall accuracy of EMR-recorded ingestion histories in the preceding 48 h was poor. The EMR was accurate in only 21.9% of cases. Neither age ≥ 65 years (odds ratio [OR] = 1.3; 95% confidence interval [CI] 0.6-2.6) nor sex (female vs. male: OR = 1.5; 95% CI 0.9-2.5) were predictors of accurate EMR history. In the inaccurate EMRs, prescription lists were more likely to include medications that the subject did not report using (78.9%), while the EMR was more likely not to capture nonprescriptions (76.1%), vitamins (73.0%), supplements (67.3%), and herbals (89.1%) that the subject reported using. Medication ingestion histories procured through triage EMR reconciliation are often inaccurate, and additional strategies are needed to obtain an accurate list. Copyright © 2015 Elsevier Inc. All rights reserved.

  9. Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

    PubMed Central

    Wittels, Kathleen; Wallenstein, Joshua; Patwari, Rahul; Patel, Sundip

    2017-01-01

    Introduction Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships. Methods We performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted. Results We received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%). Conclusion Close to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student

  10. 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

  11. The University of Washington electronic medical record experience*

    PubMed Central

    Welton, Nanette J

    2010-01-01

    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. PMID:20648254

  12. Evaluation of a BCMA’s Electronic Medication Administration Record

    PubMed Central

    Staggers, Nancy; Iribarren, Sarah; Guo, Jia-Wen; Weir, Charlene

    2015-01-01

    Barcode medication administration (BCMA) systems can reduce medication errors, but sociotechnical issues are quite common. Although crucial to nurses’ work, few usability evaluations are available for electronic medication administration record screens (eMARs). The purpose of this research was to identify current usability problems in the VA’s eMAR/BCMA system and explore how these might impact nurses’ situation awareness. Three expert evaluators used 10 tasks/elements, heuristic evaluation techniques and explored potential impacts using a situation awareness perspective. The results yielded 99 usability problems categorized into 440 heuristic violations with the largest volume in the category of Match with the Real World. Fifteen usability issues were rated as catastrophic with the Administer/Chart medications task having the most. Situational awareness was impacted at all levels, especially at Level 2, Comprehension. Usability problems point to important areas for improvement because these issues have the potential to impact nurses’ situation awareness, “at a glance” information, nurse productivity and patient safety. PMID:25601936

  13. Medical guidelines presentation and comparing with Electronic Health Record.

    PubMed

    Veselý, Arnost; Zvárová, Jana; Peleska, Jan; Buchtela, David; Anger, Zdenek

    2006-01-01

    Electronic Health Record (EHR) systems are now being developed in many places. More advanced systems provide also reminder facilities, usually based on if-then rules. In this paper we propose a method how to build the reminder facility directly upon the guideline interchange format (GLIF) model of medical guidelines. The method compares data items on the input of EHR system with medical guidelines GLIF model and is able to reveal if the input data item, that represents patient diagnosis or proposed patient treatment, contradicts with medical guidelines or not. The reminder facility can be part of EHR system itself or it can be realized by a stand-alone reminder system (SRS). The possible architecture of stand-alone reminder system is described in this paper and the advantages of stand-alone solution are discussed. The part of the EHR system could be also a browser that would present graphical GLIF model in easy to understand manner on the user screen. This browser can be data driven and focus attention of user to the relevant part of medical guidelines GLIF model.

  14. 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.

  15. Construction and Validation of Synthetic Electronic Medical Records

    PubMed Central

    Moniz, Linda; Buczak, Anna L.; Hung, Lang; Babin, Steven; Dorko, Michael; Lombardo, Joseph

    2009-01-01

    There is a current and pressing need for a test bed of electronic medical records (EMRs) to insure consistent development, validation and verification of public health related algorithms that operate on EMRs. However, access to full EMRs is limited and not generally available to the academic algorithm developers who support the public health community. This paper describes a set of algorithms that produce synthetic EMRs using real EMRs as a model. The algorithms were used to generate a pilot set of over 3000 synthetic EMRs that are currently available on CDC’s Public Health grid. The properties of the synthetic EMRs were validated, both in the entire aggregate data set and for individual (synthetic) patients. We describe how the algorithms can be extended to produce records beyond the initial pilot data set. PMID:23569572

  16. 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.

  17. 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.

  18. Financial analysis projects clear returns from electronic medical records.

    PubMed

    Schmitt, Karl F; Wofford, David A

    2002-01-01

    Implementing an electronic medical record (EMR) is a major initiative that should be undertaken only after a thoughtful analysis of the costs and benefits involved. Unfortunately, demonstrating financial returns on an EMR often is regarded as an inexact science at best, which has caused many healthcare executives to avoid adopting this technology. With the right approach, however, it is possible to demonstrate convincingly that the financial benefits will far outweigh the costs. To do this, it is necessary to involve representatives from operational areas throughout the organization, because they are best able to identify the potential for cost savings and additional revenue opportunities.

  19. Evaluation of a lecture recording system in a medical curriculum.

    PubMed

    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 length of viewings of the recordings were recorded per week for each student and correlated with the grades in each of the three courses. Attendance records were not available. The results showed considerable variability in the use of the LRS by both faculty and students during the entire semester and across all three courses, including week to week variations. Data indicated that 30% of the students did not use the LRS at all with 41% of the students using it very little (less than 10 times for a total of 131 recordings). Specific patterns of usage were identified for each of the three courses throughout the semester, with an increase in access prior or during examination weeks. However, the statistical analysis showed that there was no correlation between the final grades and the usage of LRS. Finally, a survey of the students' perception showed that 74% agreed/strongly agreed that the recordings were useful with 6% disagreeing/strongly disagreeing and 11% undecided. This study showed that the use of LRS might be a viable alternative for students unable to attend lecture due to circumstances such as illness but that more research is needed to truly understand the best pedagogical use of LRS. Copyright © 2010 American Association of Anatomists.

  20. 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.

  1. Usefulness of the functionalities of an electronic medical record on a Latin American medical web portal.

    PubMed

    Flichtentrei, Daniel; Braga, Florencia; García, Darío; Jamsech, Jorge; Otero, Carlos; Waldhorn, Martín; Luna, Daniel; de Quiros, Fernan Gonzalez Bernaldo

    2010-01-01

    The medical record is a key component in the modern health systems, a fundamental basis of higher functionalities that guaranties quality care and the possibility of improved clinical management. The dissemination of information systems for the electronic medical record (EMR) has a growing acceptance and use in developed countries. This type of recognition however has not been widespread in Latin America. Realizing this we conducted a web survey to users of a Latin American medical portal to assess their perception of the EMRs usefulness. Among the results we found that over 90% of respondents were in favor of its use, with values that exceed 80% in the analysis of the utilities by categories. More in-depth studies are needed to determine the reasons for the lack of dissemination and implementation of EMR in our region.

  2. Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge

    PubMed Central

    Liang, Catherine L; Hamann, Claus; Karson, Andrew S; Palchuk, Matvey B; McCarthy, Patricia C; Sherlock, Melanie; Turchin, Alexander; Bates, David W

    2011-01-01

    Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30 days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting. PMID:21486889

  3. Relevance of the electronic computer to hospital medical records*

    PubMed Central

    Mitchell, J. H.

    1969-01-01

    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. PMID:4898564

  4. Accessing personal medical records online: a means to what ends?

    PubMed

    Shah, Syed Ghulam Sarwar; Fitton, Richard; Hannan, Amir; Fisher, Brian; Young, Terry; Barnett, Julie

    2015-02-01

    Initiatives in the UK to enable patients to access their electronic health records (EHRs) are gathering momentum. All citizens of the European Union should have access to their records by 2015, a target that the UK has endorsed. To identify the ways in which patients used their access to their EHRs, what they sought to achieve, and the extent to which EHR access was related to the concept of making savings. An audit of patients' online access to medical records was conducted in July-August 2011 using a survey questionnaire. Two hundred and twenty six patients who were registered with two general practices in the National Health Service (NHS) located in the UK and who had accessed their personal EHRs at least twice in the preceding 12 months i.e. from July 2010 to July 2011, completed the questionnaire. Data analysis A thematic analysis of the comments that patients gave in response to the open ended questions on the questionnaire. Overall, evaluations of record access were positive. Four main themes relating to the ways in which patients accessed their records were identified: making savings, checking past activity, preparation for future action, and setting new expectations. Quite apart from any benefits of savings in healthcare resources, this study has provided qualitative evidence of the active ways in which patients may make use of access to their EHRs, many of which are in line with proportionate health management strategies. Access to personal EHRs may contribute to the development of new expectations among patients. Copyright © 2014 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.

  5. 77 FR 55221 - Agency Information Collection Activities: Report of Medical Examination and Vaccination Record...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-07

    ... 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...

  6. Consistency in performance evaluation reports and medical records.

    PubMed

    Lu, Mingshan; Ma, Ching-to Albert

    2002-12-01

    In the health care market managed care has become the latest innovation for the delivery of services. For efficient implementation, the managed care organization relies on accurate information. So clinicians are often asked to report on patients before referrals are approved, treatments authorized, or insurance claims processed. What are clinicians responses to solicitation for information by managed care organizations? The existing health literature has already pointed out the importance of provider gaming, sincere reporting, nudging, and dodging the rules. We assess the consistency of clinicians reports on clients across administrative data and clinical records. For about 1,000 alcohol abuse treatment episodes, we compare clinicians reports across two data sets. The first one, the Maine Addiction Treatment System (MATS), was an administrative data set; the state government used it for program performance monitoring and evaluation. The second was a set of medical record abstracts, taken directly from the clinical records of treatment episodes. A clinician s reporting practice exhibits an inconsistency if the information reported in MATS differs from the information reported in the medical record in a statistically significant way. We look for evidence of inconsistencies in five categories: admission alcohol use frequency, discharge alcohol use frequency, termination status, admission employment status, and discharge employment status. Chi-square tests, Kappa statistics, and sensitivity and specificity tests are used for hypothesis testing. Multiple imputation methods are employed to address the problem of missing values in the record abstract data set. For admission and discharge alcohol use frequency measures, we find, respectively, strong and supporting evidence for inconsistencies. We find equally strong evidence for consistency in reports of admission and discharge employment status, and mixed evidence on report consistency on termination status. Patterns of

  7. The Design & Implementation of a Curriculum Ladder in Medical Record Administration 1970-1973.

    ERIC Educational Resources Information Center

    Waters, Kathleen A.; Hanken, Mary Alice

    Objectives of a 3-year articulation project were (1) to design and put into effect a curriculum for medical record personnel which would provide educational progression for associate arts degree medical record technicians to baccalaureate degree medical record administration programs, (2) to research, classify, and compare curriculum content of…

  8. 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...

  9. 28 CFR 513.44 - Fees for copies of Inmate Central File and Medical Records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

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

  10. 32 CFR 310.24 - Disclosures to the public from medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Disclosures to the public from medical records... Agencies and Third Parties § 310.24 Disclosures to the public from medical records. (a) Disclosures from medical records are not only governed by the requirement of this part but also by the...

  11. 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...

  12. 29 CFR 2400.7 - Special procedures for requesting medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 9 2010-07-01 2010-07-01 false Special procedures for requesting medical records. 2400.7... COMMISSION REGULATIONS IMPLEMENTING THE PRIVACY ACT § 2400.7 Special procedures for requesting medical records. (a) Upon an individual's request for access to his medical records, including...

  13. 32 CFR 1901.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 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 are... 32 National Defense 6 2010-07-01 2010-07-01 false Special procedures for medical and...

  14. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 1 2014-01-01 2014-01-01 false Records of dosages of unsealed byproduct material for 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)...

  15. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Records of dosages of unsealed byproduct material for 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)...

  16. 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...

  17. 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,…

  18. 12 CFR 792.57 - Special procedures: Information furnished by other agencies; medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... other agencies; medical records. 792.57 Section 792.57 Banks and Banking NATIONAL CREDIT UNION...; medical records. (a) When a request for records or information from NCUA includes information furnished by... whether to disclose the record shall be made in the first instance by the system manager. (b)...

  19. 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.

  20. 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

  1. Change management - recommendations for successful electronic medical records implementation.

    PubMed

    Shoolin, J S

    2010-01-01

    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.

  2. 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

  3. Medical Record Keeping in the Summer Camp Setting.

    PubMed

    Kaufman, Laura; Holland, Jaycelyn; Weinberg, Stuart; Rosenbloom, S Trent

    2016-12-14

    Approximately one fifth of school-aged children spend a significant portion of their year at residential summer camp, and a growing number have chronic medical conditions. Camp health records are essential for safe, efficient care and for transitions between camp and home providers, yet little research exists regarding these systems. To survey residential summer camps for children to determine how camps create, store, and use camper health records. To raise awareness in the informatics community of the issues experienced by health providers working in a special pediatric care setting. We designed a web-based electronic survey concerning medical recordkeeping and healthcare practices at summer camps. 953 camps accredited by the American Camp Association received the survey. Responses were consolidated and evaluated for trends and conclusions. Of 953 camps contacted, 298 (31%) responded to the survey. Among respondents, 49.3% stated that there was no computer available at the health center, and 14.8% of camps stated that there was not any computer available to health staff at all. 41.1% of camps stated that internet access was not available. The most common complaints concerning recordkeeping practices were time burden, adequate completion, and consistency. Summer camps in the United States make efforts to appropriately document healthcare given to campers, but inconsistency and inefficiency may be barriers to staff productivity, staff satisfaction, and quality of care. Survey responses suggest that the current methods used by camps to document healthcare cause limitations in consistency, efficiency, and communications between providers, camp staff, and parents. As of 2012, survey respondents articulated need for a standard software to document summer camp healthcare practices that accounts for camp-specific needs. Improvement may be achieved if documentation software offers the networking capability, simplicity, pediatrics-specific features, and avoidance of

  4. [Quality recording of information in the health centre medical records on the use of analgesic and anti-inflammatory drugs].

    PubMed

    González-Navarro, M D; Gómez-Zapata, M; Pérez-Cárceles, M D; Poveda-Siles, S; Luna-Maldonado, A

    2012-01-01

    To examine medical records within a health centre to determine whether there are data in the information process on the secondary effects and interactions of analgesic and anti-inflammatory drugs, and to determine the patient profile as regards whether or not this information is recorded in their medical records. Descriptive, cross-sectional study based on electronic medical records in the Mariano Yago Primary Care Centre in Yecla (Murcia), Spain. A systematic random sample of 232 electronic medical records was reviewed. All the 232 patients, of legal age, gave their consent to review of their electronic medical records for the purposes of the study. The percentage of doctors who recorded the fact that they had provided information regarding secondary effects and non-compatibilities of the prescription of analgesic and antiinflammatory drugs was 21.6%. The factors involved in the non- recording of this information in the medical record were the type of prescription, the type of analgesic and anti-inflammatory drug prescribed, glomerular filtration, and adequate gastrointestinal protection. The degree of compliance to patients rights to information about treatment with analgesic and anti-inflammatory drugs is low.

  5. The influence of electronic medical record usage on nonverbal communication in the medical interview.

    PubMed

    McGrath, John M; Arar, Nedal H; Pugh, Jacqueline A

    2007-06-01

    This study examined nonverbal communication in relation to electronic medical record (EMR) use during the medical interview. Six physicians were videotaped during their consultations with 50 different patients at a single setting Veterans Administration Hospital. Three different office spatial designs were identified and named 'open,' 'closed' and 'blocked'. The ;open' arrangement put physicians in a position to establish better eye contact and physical orientation than did the alternative 'closed' and 'blocked' office configurations. Physicians who accessed the EMR and took 'breakpoints' (short periods of no computer use and sustained eye contact with patients) used more nonverbal cues than physicians who tended to talk with their patients while continuously working on the computer. Long pauses in conversational turn taking associated with EMR use may have positively influenced doctor-patient communication. High EMR use interviews were associated with patients asking more questions than they did in low EMR use interviews. Implications for medical education and future research are discussed.

  6. 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

  7. Challenges of self-reported medical conditions and electronic medical records among members of a large military cohort

    PubMed Central

    Smith, Besa; Chu, Laura K; Smith, Tyler C; Amoroso, Paul J; Boyko, Edward J; Hooper, Tomoko I; Gackstetter, Gary D; Ryan, Margaret AK

    2008-01-01

    Background Self-reported medical history data are frequently used in epidemiological studies. Self-reported diagnoses may differ from medical record diagnoses due to poor patient-clinician communication, self-diagnosis in the absence of a satisfactory explanation for symptoms, or the "health literacy" of the patient. Methods The US Department of Defense military health system offers a unique opportunity to evaluate electronic medical records with near complete ascertainment while on active duty. This study compared 38 self-reported medical conditions to electronic medical record data in a large population-based US military cohort. The objective of this study was to better understand challenges and strengths in self-reporting of medical conditions. Results Using positive and negative agreement statistics for less-prevalent conditions, near-perfect negative agreement and moderate positive agreement were found for the 38 diagnoses. Conclusion This report highlights the challenges of using self-reported medical data and electronic medical records data, but illustrates that agreement between the two data sources increases with increased surveillance period of medical records. Self-reported medical data may be sufficient for ruling out history of a particular condition whereas prevalence studies may be best served by using an objective measure of medical conditions found in electronic healthcare records. Defining medical conditions from multiple sources in large, long-term prospective cohorts will reinforce the value of the study, particularly during the initial years when prevalence for many conditions may still be low. PMID:18644098

  8. Utilizing Electronic Medical Records to Discover Changing Trends of Medical Behaviors Over Time*

    PubMed Central

    Yin, Liangying; Dong, Wei; He, Chunhua; Duan, Huilong

    2017-01-01

    Summary Objectives Medical behaviors are playing significant roles in the delivery of high quality and cost-effective health services. Timely discovery of changing frequencies of medical behaviors is beneficial for the improvement of health services. The main objective of this work is to discover the changing trends of medical behaviors over time. Methods This study proposes a two-steps approach to detect essential changing patterns of medical behaviors from Electronic Medical Records (EMRs). In detail, a probabilistic topic model, i.e., Latent Dirichlet allocation (LDA), is firstly applied to disclose yearly treatment patterns in regard to the risk stratification of patients from a large volume of EMRs. After that, the changing trends by comparing essential/critical medical behaviors in a specific time period are detected and analyzed, including changes of significant patient features with their values, and changes of critical treatment interventions with their occurring time stamps. Results We verify the effectiveness of the proposed approach on a clinical dataset containing 12,152 patient cases with a time range of 10 years. Totally, 135 patients features and 234 treatment interventions in three treatment patterns were selected to detect their changing trends. In particular, evolving trends of yearly occurring probabilities of the selected medical behaviors were categorized into six content changing patterns (i.e, 112 growing, 123 declining, 43 up-down, 16 down-up, 35 steady, and 40 jumping), using the proposed approach. Besides, changing trends of execution time of treatment interventions were classified into three occurring time changing patterns (i.e., 175 early-implemented, 50 steady-implemented and 9 delay-implemented). Conclusions Experimental results show that our approach has an ability to utilize EMRs to discover essential evolving trends of medical behaviors, and thus provide significant potential to be further explored for health services redesign and

  9. The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences.

    PubMed

    Sayyah-Melli, Manizheh; Nikravan Mofrad, Malahat; Amini, Abolghasem; Piri, Zakieh; Ghojazadeh, Morteza; Rahmani, Vahideh

    2017-09-01

    Introduction: Medical records contain valuable information about a patient's medical history and treatment. Patient safety is one of the most important dimensions of health care quality assurance and performance improvement. Completing the process of documentation is necessary to continue patient care and continuous quality improvement of basic services. The aim of the present study was to evaluate the effect of medical recording education on the quantity and quality of recording in gynecology residents of Tabriz University of Medical Sciences. Methods: This study is a quasi-experimental study and was conducted at Al-Zahra Teaching Hospital, Tabriz, Iran, in 2016. Thirty-two second through fourth year gynecologic residents of Tabriz University of Medical Sciences who were willing to participate in the study were included by census sampling and participated in training workshop. Three evaluators reviewed the residents' records before and after training course by a checklist. Statistical analyses were performed using SPSS 13 software. P-values less than 0.05 were considered statistically significant. Results: The results showed that before the intervention, there were significant differences in the quantity of information status among the evaluators and no significant difference was observed in the recording of qualitative status. After the workshop, among the 3 evaluators, there were also significant differences in the quantity of data recording status; however, no significant change was observed in recording of qualitative status. Conclusion: The study findings revealed that a sectional training course of correct and standardized medical records has no effect on reforming the process of recording.

  10. Use of Electronic Medication Administration Records to Reduce Perceived Stress and Risk of Medication Errors in Nursing Homes.

    PubMed

    Alenius, Malin; Graf, Peter

    2016-07-01

    Concerns have been raised about the effects of current medication administration processes on the safety of many of the aspects of medication administration. Keeping electronic medication administration records could decrease many of these problems. Unfortunately, there has not been much research on this topic, especially in nursing homes. A prospective case-control survey was consequently performed at two nursing homes; the electronic record system was introduced in one, whereas the other continued to use paper records. The personnel were asked to fill in a questionnaire of their perceptions of stress and risk of medication errors at baseline (n = 66) and 20 weeks after the intervention group had started recording medication administration electronically (n = 59). There were statistically significant decreases in the perceived risk of omitting a medication, of medication errors occurring because of communication problems, and of medication errors occurring because of inaccurate medication administration records in the intervention group (all P < .01 vs the control group). The perceived overall daily stress levels were also reduced in the intervention group (P < .05). These results indicate that the utilization of electronic medication administration records will reduce many of the concerns regarding the medication administration process.

  11. 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.

  12. 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.

  13. 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

  14. Electronic medical record use in pediatric primary care

    PubMed Central

    Alessandrini, Evaline A; Forrest, Christopher B; Khan, Saira; Localio, A Russell; Gerber, Andreas

    2010-01-01

    Objectives To characterize patterns of electronic medical record (EMR) use at pediatric primary care acute visits. Design Direct observational study of 529 acute visits with 27 experienced pediatric clinician users. Measurements For each 20 s interval and at each stage of the visit according to the Davis Observation Code, we recorded whether the physician was communicating with the family only, using the computer while communicating, or using the computer without communication. Regression models assessed the impact of clinician, patient and visit characteristics on overall visit length, time spent interacting with families, and time spent using the computer while interacting. Results The mean overall visit length was 11:30 (min:sec) with 9:06 spent in the exam room. Clinicians used the EMR during 27% of exam room time and at all stages of the visit (interacting, chatting, and building rapport; history taking; formulation of the diagnosis and treatment plan; and discussing prevention) except the physical exam. Communication with the family accompanied 70% of EMR use. In regression models, computer documentation outside the exam room was associated with visits that were 11% longer (p=0.001), and female clinicians spent more time using the computer while communicating (p=0.003). Limitations The 12 study practices shared one EMR. Conclusions Among pediatric clinicians with EMR experience, conversation accompanies most EMR use. Our results suggest that efforts to improve EMR usability and clinician EMR training should focus on use in the context of doctor–patient communication. Further study of the impact of documentation inside versus outside the exam room on productivity is warranted. PMID:21134975

  15. 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.

  16. 38 CFR 1.513 - Disclosure of information contained in Armed Forces service and related medical records in...

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... contained in Armed Forces service and related medical records in Department of Veterans Affairs custody. 1... information contained in Armed Forces service and related medical records in Department of Veterans Affairs.... (b) Medical records. Information contained in the medical records (including clinical records...

  17. 38 CFR 1.513 - Disclosure of information contained in Armed Forces service and related medical records in...

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... contained in Armed Forces service and related medical records in Department of Veterans Affairs custody. 1... information contained in Armed Forces service and related medical records in Department of Veterans Affairs.... (b) Medical records. Information contained in the medical records (including clinical records...

  18. 38 CFR 1.513 - Disclosure of information contained in Armed Forces service and related medical records in...

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... contained in Armed Forces service and related medical records in Department of Veterans Affairs custody. 1... information contained in Armed Forces service and related medical records in Department of Veterans Affairs.... (b) Medical records. Information contained in the medical records (including clinical records...

  19. 33 CFR 150.604 - Who controls access to medical monitoring and exposure records?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 33 Navigation and Navigable Waters 2 2010-07-01 2010-07-01 false Who controls access to medical... Health Safety and Health (general) § 150.604 Who controls access to medical monitoring and exposure records? If medical monitoring is performed or exposure records are maintained by an employer, the...

  20. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 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,...

  1. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 6 2012-07-01 2012-07-01 false Special procedures for medical/psychiatric... 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...

  2. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 6 2014-07-01 2014-07-01 false Special procedures for medical/psychiatric... 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...

  3. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 6 2013-07-01 2013-07-01 false Special procedures for medical/psychiatric... 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...

  4. 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.

  5. 77 FR 64387 - Agency Information Collection (Request for and Authorization To Release Medical Records or Health...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-19

    ... AFFAIRS Agency Information Collection (Request for and Authorization To Release Medical Records or Health... Release Medical Records or Health Information, VA Form 10-5345. b. Individual's Request for a Copy of... Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue...

  6. 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…

  7. 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 and...

  8. 32 CFR 326.11 - Special procedures for disclosure of medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... psychological records. 326.11 Section 326.11 National Defense Department of Defense (Continued) OFFICE OF THE... Special procedures for disclosure of medical and psychological records. When requested medical and psychological records are not exempt from disclosure, the PA Coordinator may determine which non-exempt...

  9. 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...

  10. 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

  11. 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.

  12. A critical pathway for electronic medical record selection.

    PubMed Central

    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. PMID:11825192

  13. 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

  14. Implementation of electronic medical records: theory-informed qualitative study.

    PubMed

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

    2011-10-01

    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). 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. Toronto, Ont. Twelve community-based family physicians. 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. 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. 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.

  15. Development of mobile platform integrated with existing electronic medical records.

    PubMed

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

    2014-07-01

    This paper describes a mobile Electronic Medical Record (EMR) platform designed to manage and utilize the existing EMR and mobile application with optimized resources. 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. 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. 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.

  16. 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

  17. Improving the medical records department processes by lean management.

    PubMed

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

    2015-01-01

    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. 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. 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. 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. 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. 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. The study represents one of the few attempts trying to eliminate wastes in the MRD.

  18. 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

  19. 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.

  20. Evaluating privacy-preserving record linkage using cryptographic long-term keys and multibit trees on large medical datasets.

    PubMed

    Brown, Adrian P; Borgs, Christian; Randall, Sean M; Schnell, Rainer

    2017-06-08

    Integrating medical data using databases from different sources by record linkage is a powerful technique increasingly used in medical research. Under many jurisdictions, unique personal identifiers needed for linking the records are unavailable. Since sensitive attributes, such as names, have to be used instead, privacy regulations usually demand encrypting these identifiers. The corresponding set of techniques for privacy-preserving record linkage (PPRL) has received widespread attention. One recent method is based on Bloom filters. Due to superior resilience against cryptographic attacks, composite Bloom filters (cryptographic long-term keys, CLKs) are considered best practice for privacy in PPRL. Real-world performance of these techniques using large-scale data is unknown up to now. Using a large subset of Australian hospital admission data, we tested the performance of an innovative PPRL technique (CLKs using multibit trees) against a gold-standard derived from clear-text probabilistic record linkage. Linkage time and linkage quality (recall, precision and F-measure) were evaluated. Clear text probabilistic linkage resulted in marginally higher precision and recall than CLKs. PPRL required more computing time but 5 million records could still be de-duplicated within one day. However, the PPRL approach required fine tuning of parameters. We argue that increased privacy of PPRL comes with the price of small losses in precision and recall and a large increase in computational burden and setup time. These costs seem to be acceptable in most applied settings, but they have to be considered in the decision to apply PPRL. Further research on the optimal automatic choice of parameters is needed.

  1. [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.

  2. 10 CFR 9.35 - Duplication fees.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Duplication fees. 9.35 Section 9.35 Energy NUCLEAR REGULATORY COMMISSION PUBLIC RECORDS Freedom of Information Act Regulations § 9.35 Duplication fees. (a)(1...″ reduced). Pages 11″ × 17″ are $0.30 per page. Pages larger than 11″ × 17″, including engineering...

  3. The Effects of Promoting Patient Access to Medical Records: A Review

    PubMed Central

    Ross, Stephen E.; Lin, Chen-Tan

    2003-01-01

    The Health Insurance Privacy and Portability Act (HIPPA) stipulates that patients must be permitted to review and amend their medical records. As information technology makes medical records more accessible to patients, it may become more commonplace for patients to review their records routinely. This article analyzes the potential benefits and drawbacks of facilitating patient access to the medical record by reviewing previously published research. Previous research includes analysis of clinical notes, surveys of patients and practitioners, and studies of patient-accessible medical records. Overall, studies suggest the potential for modest benefits (for instance, in enhancing doctor-patient communication). Risks (for instance, increasing patient worry or confusion) appear to be minimal in medical patients. The studies, however, were of limited quality and low statistical power to detect the variety of outcomes that may result from implementation of a patient-accessible medical record. The data from these studies lay the foundation for future research. PMID:12595402

  4. Privacy Impact Assessment for the Medical and Research Study Records of Human Volunteers

    EPA Pesticide Factsheets

    The Medical & Research Study Records of Human Volunteers System collects demographic and medical information on subjects who participate in research. Learn how this data is collected, used, access to the data, and the purpose of data collection.

  5. Acupuncture and chiropractic care: utilization and electronic medical record capture.

    PubMed

    Elder, Charles; DeBar, Lynn; Ritenbaugh, Cheryl; Vollmer, William; Deyo, Richard A; Dickerson, John; Kindler, Lindsay

    2015-07-01

    To describe acupuncture and chiropractic use among patients with chronic musculoskeletal pain (CMP) at a health maintenance organization, and explore issues of benefit design and electronic medical record (EMR) capture. Cross-sectional survey. Kaiser Permanente members meeting EMR diagnostic criteria for CMP were invited to participate. The survey included questions about self-identified presence of CMP, use of acupuncture and chiropractic care, use of ancillary self-care modalities, and communication with conventional medicine practitioners. Analysis of survey data was supplemented with a retrospective review of EMR utilization data. Of 6068 survey respondents, 32% reported acupuncture use, 47% reported chiropractic use, 21% used both, and 42% used neither. For 25% of patients using acupuncture and 43% of those using chiropractic care, utilization was undetected by the EMR. Thirty-five percent of acupuncture users and 42% of chiropractic users did not discuss this care with their health maintenance organization (HMO) clinicians. Among chiropractic users, those accessing care out of plan were older (P < .01), were more likely to use long-term opioids (P = .03), and had more pain diagnoses (P = .01) than those accessing care via clinician referral or self-referral. For acupuncture, those using the clinician referral mechanism exhibited these same characteristics. A majority of participants had used acupuncture, chiropractic care, or both. While benefit structure may materially influence utilization patterns, many patients with CMP use acupuncture and chiropractic care without regard to their insurance coverage. A substantial percentage of acupuncture and chiropractic use thus occurs beyond detection of EMR systems, and many patients do not report such care to their HMO clinicians.

  6. Identifying Axial Spondyloarthritis in Electronic Medical Records of US Veterans.

    PubMed

    Walsh, Jessica A; Shao, Yijun; Leng, Jianwei; He, Tao; Teng, Chia-Chen; Redd, Doug; Treitler Zeng, Qing; Burningham, Zachary; Clegg, Daniel O; Sauer, Brian C

    2017-09-01

    Large database research in axial spondyloarthritis (SpA) is limited by a lack of methods for identifying most types of axial SpA. Our objective was to develop methods for identifying axial SpA concepts in the free text of documents from electronic medical records. Veterans with documents in the national Veterans Health Administration Corporate Data Warehouse between January 1, 2005 and June 30, 2015 were included. Methods were developed for exploring, selecting, and extracting meaningful terms that were likely to represent axial SpA concepts. With annotation, clinical experts reviewed sections of text containing the meaningful terms (snippets) and classified the snippets according to whether or not they represented the intended axial SpA concept. With natural language processing (NLP) tools, computers were trained to replicate the clinical experts' snippet classifications. Three axial SpA concepts were selected by clinical experts, including sacroiliitis, terms including the prefix spond*, and HLA-B27 positivity (HLA-B27+). With supervised machine learning on annotated snippets, NLP models were developed with accuracies of 91.1% for sacroiliitis, 93.5% for spond*, and 97.2% for HLA-B27+. With independent validation, the accuracies were 92.0% for sacroiliitis, 91.0% for spond*, and 99.0% for HLA-B27+. We developed feasible and accurate methods for identifying axial SpA concepts in the free text of clinical notes. Additional research is required to determine combinations of concepts that will accurately identify axial SpA phenotypes. These novel methods will facilitate previously impractical observational research in axial SpA and may be applied to research with other diseases. © 2016, American College of Rheumatology.

  7. 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

  8. 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.

  9. Consumers' perceptions of patient-accessible electronic medical records.

    PubMed

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

    2013-08-26

    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. 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. This qualitative study used 4 focus groups with 28 low education level, English-speaking consumers in June and July 2010, in New York City. 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. 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 engaging, and have user-friendly navigation.

  10. Hospital electronic medical record enterprise application strategies: do they matter?

    PubMed

    Fareed, Naleef; Ozcan, Yasar A; DeShazo, Jonathan P

    2012-01-01

    Successful implementations and the ability to reap the benefits of electronic medical record (EMR) systems may be correlated with the type of enterprise application strategy that an administrator chooses when acquiring an EMR system. Moreover, identifying the most optimal enterprise application strategy is a task that may have important linkages with hospital performance. This study explored whether hospitals that have adopted differential EMR enterprise application strategies concomitantly differ in their overall efficiency. Specifically, the study examined whether hospitals with a single-vendor strategy had a higher likelihood of being efficient than those with a best-of-breed strategy and whether hospitals with a best-of-suite strategy had a higher probability of being efficient than those with best-of-breed or single-vendor strategies. A conceptual framework was used to formulate testable hypotheses. A retrospective cross-sectional approach using data envelopment analysis was used to obtain efficiency scores of hospitals by EMR enterprise application strategy. A Tobit regression analysis was then used to determine the probability of a hospital being inefficient as related to its EMR enterprise application strategy, while moderating for the hospital's EMR "implementation status" and controlling for hospital and market characteristics. The data envelopment analysis of hospitals suggested that only 32 hospitals were efficient in the study's sample of 2,171 hospitals. The results from the post hoc analysis showed partial support for the hypothesis that hospitals with a best-of-suite strategy were more likely to be efficient than those with a single-vendor strategy. This study underscores the importance of understanding the differences between the three strategies discussed in this article. On the basis of the findings, hospital administrators should consider the efficiency associations that a specific strategy may have compared with another prior to moving toward

  11. 7 CFR 110.5 - Availability of records to facilitate medical treatment.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... or record information to submit pesticide poisoning incident reports to appropriate state or federal... APPLICATORS; SURVEYS AND REPORTS § 110.5 Availability of records to facilitate medical treatment. (a) When the...

  12. 7 CFR 110.5 - Availability of records to facilitate medical treatment.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... or record information to submit pesticide poisoning incident reports to appropriate state or federal... APPLICATORS; SURVEYS AND REPORTS § 110.5 Availability of records to facilitate medical treatment. (a) When the...

  13. 7 CFR 110.5 - Availability of records to facilitate medical treatment.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... or record information to submit pesticide poisoning incident reports to appropriate state or federal... APPLICATORS; SURVEYS AND REPORTS § 110.5 Availability of records to facilitate medical treatment. (a) When the...

  14. A context-aware approach for progression tracking of medical concepts in electronic medical records.

    PubMed

    Chang, Nai-Wen; Dai, Hong-Jie; Jonnagaddala, Jitendra; Chen, Chih-Wei; Tsai, Richard Tzong-Han; Hsu, Wen-Lian

    2015-12-01

    Electronic medical records (EMRs) for diabetic patients contain information about heart disease risk factors such as high blood pressure, cholesterol levels, and smoking status. Discovering the described risk factors and tracking their progression over time may support medical personnel in making clinical decisions, as well as facilitate data modeling and biomedical research. Such highly patient-specific knowledge is essential to driving the advancement of evidence-based practice, and can also help improve personalized medicine and care. One general approach for tracking the progression of diseases and their risk factors described in EMRs is to first recognize all temporal expressions, and then assign each of them to the nearest target medical concept. However, this method may not always provide the correct associations. In light of this, this work introduces a context-aware approach to assign the time attributes of the recognized risk factors by reconstructing contexts that contain more reliable temporal expressions. The evaluation results on the i2b2 test set demonstrate the efficacy of the proposed approach, which achieved an F-score of 0.897. To boost the approach's ability to process unstructured clinical text and to allow for the reproduction of the demonstrated results, a set of developed .NET libraries used to develop the system is available at https://sites.google.com/site/hongjiedai/projects/nttmuclinicalnet.

  15. The development and evaluation of a new coding system for medical records.

    PubMed

    Papazissis, Elias

    2014-01-01

    The present study aims to develop a simple, reliable and easy tool enabling clinicians to codify the major part of individualized medical details (patient history and findings of physical examination) quickly and easily in routine medical practice, by entering data to a purpose-built software application, using structure data elements and detailed medical illustrations. We studied medical records of 9,320 patients and we extracted individualized medical details. We recorded the majority of symptoms and the majority of findings of physical examination into the system, which was named IMPACT® (Intelligent Medical Patient Record and Coding Tool). Subsequently the system was evaluated by clinicians, based on the examination of 1206 patients. The evaluation results showed that IMPACT® is an efficient tool, easy to use even under time-pressing conditions. IMPACT® seems to be a promising tool for illustration-guided, structured data entry of medical narrative, in electronic patient records.

  16. The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences

    PubMed Central

    Sayyah-Melli, Manizheh; Nikravan Mofrad, Malahat; Amini, Abolghasem; Piri, Zakieh; Ghojazadeh, Morteza; Rahmani, Vahideh

    2017-01-01

    Introduction: Medical records contain valuable information about a patient's medical history and treatment. Patient safety is one of the most important dimensions of health care quality assurance and performance improvement. Completing the process of documentation is necessary to continue patient care and continuous quality improvement of basic services. The aim of the present study was to evaluate the effect of medical recording education on the quantity and quality of recording in gynecology residents of Tabriz University of Medical Sciences. Methods: This study is a quasi-experimental study and was conducted at Al-Zahra Teaching Hospital, Tabriz, Iran, in 2016. Thirty-two second through fourth year gynecologic residents of Tabriz University of Medical Sciences who were willing to participate in the study were included by census sampling and participated in training workshop. Three evaluators reviewed the residents’ records before and after training course by a checklist. Statistical analyses were performed using SPSS 13 software. P-values less than 0.05 were considered statistically significant. Results: The results showed that before the intervention, there were significant differences in the quantity of information status among the evaluators and no significant difference was observed in the recording of qualitative status. After the workshop, among the 3 evaluators, there were also significant differences in the quantity of data recording status; however, no significant change was observed in recording of qualitative status. Conclusion: The study findings revealed that a sectional training course of correct and standardized medical records has no effect on reforming the process of recording. PMID:28971078

  17. A comparison of medical record with billing diagnostic information associated with ambulatory medical care.

    PubMed Central

    Studney, D R; Hakstian, A R

    1981-01-01

    The degree of similarity between diagnostic information furnished with claims and that simultaneously entered into the medical record was estimated for 1,215 private office visits in British Columbia, Canada. For each visit, claim card and chart diagnoses were compared by having three independent internists (blinded to source and type of the data) make judgments about each diagnostic pair. The judges were highly consistent internally and their judgments were stable over time. In 40 per cent of cases chart and claims data were judged dissimilar, and in 38 per cent of cases claims data were judged more valuable as a reflection of the primary problem treated. The degree of judged similarity of chart and claims data correlated significantly and negatively with physician workload, income, and judges' preference for the billing card diagnosis. We conclude that in using claims data to determine the content of ambulatory visits, independent validation of such data may be important. PMID:7457683

  18. Complete tracheal duplication with unilateral atelectasis in an adult.

    PubMed

    Chihaya, Keisuke; Yamashiro, Tsuneo; Matsuoka, Shin; Nobuyama, Seiichi; Handa, Hiroshi; Inoue, Takeo; Kida, Hirotaka; Kurimoto, Noriaki; Matsushita, Shoichiro; Fujikawa, Atsuko; Kurihara, Yasuyuki; Mineshita, Masamichi; Miyazawa, Teruomi; Nakajima, Yasuo

    2014-01-01

    Duplication of the trachea is an extremely rare condition that has been infrequently reported in the medical literature. We report an adult case with complete tracheal duplication associated with unilateral atelectasis, which was incidentally detected by computed tomography. Tracheal duplication should be considered as a possible cause of severe atelectasis in adults.

  19. 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 schedule…

  20. 29 CFR 1926.33 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 8 2010-07-01 2010-07-01 false Access to employee exposure and medical records. 1926.33 Section 1926.33 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Health Provisions § 1926.33 Access to employee exposure and medical records. Note: The...

  1. 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 schedule…

  2. 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…

  3. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 45 Public Welfare 1 2010-10-01 2010-10-01 false Special procedures for notification of or access to medical records. 5b.6 Section 5b.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION PRIVACY ACT REGULATIONS § 5b.6 Special procedures for notification of or access to medical records. (a) General. An individual...

  4. Roles, Functions, Training, and Proficiency Tests for Medical Record Personnel: A Guide to Curriculum Management.

    ERIC Educational Resources Information Center

    Clark, Fredric A.

    The curriculum management guide serves as an aid to medical record teachers and other medical record educators. It is designed to provide them with a useful tool to improve student performances by improved administration and management of programs. The guide documents one possible systematic approach to professional and vocational curriculum…

  5. 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…

  6. 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…

  7. 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…

  8. 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…

  9. Access to Medical and Psychiatric Records: Proposed Legislation

    ERIC Educational Resources Information Center

    Felch, Erica

    1976-01-01

    This commentary reviews the history and ideology of nondisclosure, considers the realities of modern treatment and record-keeping, and describes the contemporary legal dilemma in this context. Model legislation is proposed to provide patients a property right of direct access to their records. (LBH)

  10. Accuracy of dialysis medical records in determining patients' interest in and suitability for transplantation.

    PubMed

    Huml, Anne M; Sullivan, Catherine M; Pencak, Julie A; Sehgal, Ashwini R

    2013-01-01

    We sought to determine the accuracy of dialysis medical records in identifying patients' interest in and suitability for transplantation. Cluster randomized controlled trial. A total of 167 patients recruited from 23 hemodialysis facilities. Navigators met with intervention patients to provide transplant information and assistance. Control patients continued to receive usual care. Agreement at study initiation between medical records and (i) patient self-reported interest in transplantation and (ii) study assessments of medical suitability for transplant referral. Medical record assessments, self-reports, and study assessments of patient's interest in and suitability for transplantation. There was disagreement between medical records and patient self-reported interest in transplantation for 66 (40%) of the 167 study patients. In most of these cases, patients reported being more interested in transplantation than their medical records indicated. The study team determined that all 92 intervention patients were medically suitable for transplant referral. However, for 38 (41%) intervention patients, medical records indicated that they were not suitable. About two-thirds of these patients successfully moved forward in the transplant process. Dialysis medical records are frequently inaccurate in determining patient's interest in and suitability for transplantation. © 2013 John Wiley & Sons A/S.

  11. Accuracy of Dialysis Medical Records in Determining Patient Interest in and Suitability for Transplantation

    PubMed Central

    Huml, Anne M.; Sullivan, Catherine M.; Pencak, Julie A.; Sehgal, Ashwini R.

    2013-01-01

    Background We sought to determine the accuracy of dialysis medical records in identifying patient interest in and suitability for transplantation. Study Design Cluster randomized controlled trial Setting and Participants 167 patients recruited from 23 hemodialysis facilities. Intervention Navigators met with intervention patients to provide transplant information and assistance. Control patients continued to receive usual care. Outcomes Agreement at study initiation between medical records and (a) patient self-reported interest in transplantation and (b) study assessments of medical suitability for transplant referral. Measurements Medical record assessments, self-reports, and study assessments of patient interest in and suitability for transplantation. Results There was disagreement between medical records and patient self-reported interest in transplantation for 66 (40%) of the 167 study patients. In most of these cases, patients reported being more interested in transplantation than their medical records indicated. The study team determined that all 92 intervention patients were medically suitable for transplant referral. However, for 38 (41%) intervention patients, medical records indicated that they were not suitable. About two-thirds of these patients successfully moved forward in the transplant process. Conclusion Dialysis medical records are frequently inaccurate in determining patient interest in and suitability for transplantation. PMID:23803012

  12. Rapid Identification of Myocardial Infarction Risk Associated With Diabetes Medications Using Electronic Medical Records

    PubMed Central

    Brownstein, John S.; Murphy, Shawn N.; Goldfine, Allison B.; Grant, Richard W.; Sordo, Margarita; Gainer, Vivian; Colecchi, Judith A.; Dubey, Anil; Nathan, David M.; Glaser, John P.; Kohane, Isaac S.

    2010-01-01

    OBJECTIVE To assess the ability to identify potential association(s) of diabetes medications with myocardial infarction using usual care clinical data obtained from the electronic medical record. RESEARCH DESIGN AND METHODS We defined a retrospective cohort of patients (n = 34,253) treated with a sulfonylurea, metformin, rosiglitazone, or pioglitazone in a single academic health care network. All patients were aged >18 years with at least one prescription for one of the medications between 1 January 2000 and 31 December 2006. The study outcome was acute myocardial infarction requiring hospitalization. We used a cumulative temporal approach to ascertain the calendar date for earliest identifiable risk associated with rosiglitazone compared with that for other therapies. RESULTS Sulfonylurea, metformin, rosiglitazone, or pioglitazone therapy was prescribed for 11,200, 12,490, 1,879, and 806 patients, respectively. A total of 1,343 myocardial infarctions were identified. After adjustment for potential myocardial infarction risk factors, the relative risk for myocardial infarction with rosiglitazone was 1.3 (95% CI 1.1–1.6) compared with sulfonylurea, 2.2 (1.6–3.1) compared with metformin, and 2.2 (1.5–3.4) compared with pioglitazone. Prospective surveillance using these data would have identified increased risk for myocardial infarction with rosiglitazone compared with metformin within 18 months of its introduction with a risk ratio of 2.1 (95% CI 1.2–3.8). CONCLUSIONS Our results are consistent with a relative adverse cardiovascular risk profile for rosiglitazone. Our use of usual care electronic data sources from a large hospital network represents an innovative approach to rapid safety signal detection that may enable more effective postmarketing drug surveillance. PMID:20009093

  13. Cancer patients' attitudes and experiences of online access to their electronic medical records: A qualitative study.

    PubMed

    Rexhepi, Hanife; Åhlfeldt, Rose-Mharie; Cajander, Åsa; Huvila, Isto

    2016-07-19

    Patients' access to their online medical records serves as one of the cornerstones in the efforts to increase patient engagement and improve healthcare outcomes. The aim of this article is to provide in-depth understanding of cancer patients' attitudes and experiences of online medical records, as well as an increased understanding of the complexities of developing and launching e-Health services. The study result confirms that online access can help patients prepare for doctor visits and to understand their medical issues. In contrast to the fears of many physicians, the study shows that online access to medical records did not generate substantial anxiety, concerns or increased phone calls to the hospital.

  14. Plant Genome Duplication Database.

    PubMed

    Lee, Tae-Ho; Kim, Junah; Robertson, Jon S; Paterson, Andrew H

    2017-01-01

    Genome duplication, widespread in flowering plants, is a driving force in evolution. Genome alignments between/within genomes facilitate identification of homologous regions and individual genes to investigate evolutionary consequences of genome duplication. PGDD (the Plant Genome Duplication Database), a public web service database, provides intra- or interplant genome alignment information. At present, PGDD contains information for 47 plants whose genome sequences have been released. Here, we describe methods for identification and estimation of dates of genome duplication and speciation by functions of PGDD.The database is freely available at http://chibba.agtec.uga.edu/duplication/.

  15. Electronic medical records as tools for quality improvement in ambulatory practice: theory and a case study.

    PubMed

    Ornstein, S M; Jenkins, R G; MacFarlane, L; Glaser, A; Snyder, K; Gundrum, T

    1998-11-01

    Information management is critical in today's health care environment. Traditional paper-based medical records are inadequate information management tools. Electronic medical records (EMRs) overcome many problems with paper records and are ideally suited to help physicians increase productivity and improve the quality of care they provide. The Department of Family Medicine at the Medical University of South Carolina uses the Practice Partner Patient Record EMR system. Department members have developed a quality improvement model based on this EMR system. The model has been used to improve care for acute bronchitis, diabetes mellitus, tobacco abuse, asthma, and postmenopausal osteoporosis.

  16. Feasibility Study for Establishing Three Medical Record Related Programs. Research Report Series Volume XIV, No. 12.

    ERIC Educational Resources Information Center

    William Rainey Harper Coll., Palatine, IL. Office of Planning and Research.

    In November 1985, a survey was conducted at William Rainey Harper College (WRHC), in Illinois, to test the feasibility of establishing programs for medical record technicians, medical coders, and utilization analysts. The survey instrument was mailed to 1,232 hospitals, medical care facilities, nursing homes, physicians' and dentists' offices, and…

  17. 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 may...

  18. 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 may...

  19. 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 may...

  20. 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 may...

  1. 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...

  2. The effects of an electronic medical record on the completeness of documentation in the anesthesia record.

    PubMed

    Jang, Junghwa; Yu, Seung Hum; Kim, Chun-Bae; Moon, Youngkyu; Kim, Sukil

    2013-08-01

    The purpose of this study is to evaluate the completeness of anesthesia recording before and after the introduction of an electronic anesthesia record. The study was conducted in a Korean teaching hospital where the EMR was implemented in October 2008. One hundred paper anesthesia records from July to September 2008 and 150 electronic anesthesia records during the same period in 2009 were randomly sampled. Thirty-four essential items were selected out of all the anesthesia items and grouped into automatically transferred items and manual entry items. 1, .5 and 0 points were given for each item of complete entry, incomplete entry and no entry respectively. The completeness of documentation was defined as the sum of the scores. The influencing factors on the completeness of documentation were evaluated in total and by the groups. The average completeness score of the electronic anesthesia records was 3.15% higher than that of the paper records. A multiple regression model showed the type of the anesthesia record was a significant factor on the completeness of anesthesia records in all items (β=.98, p<.05) and automatically transferred items (β=.56, p<.01). The type of the anesthesia records had no influence on the completeness in manual entry items. The completeness of an anesthesia record was improved after the implementation of the electronic anesthesia record. The reuse of the data from the EMR was the main contributor to the improved completeness. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

  3. Special requirements of electronic medical record systems in obstetrics and gynecology.

    PubMed

    McCoy, Michael J; Diamond, Anne M; Strunk, Albert L

    2010-07-01

    There is growing recognition of the importance and potential benefit of information technology and electronic medical records in providing quality care for women. Incorporation of obstetrician-gynecologist-specific requirements by electronic medical record vendors is essential to achieve appropriate electronic medical record functionality for obstetrician-gynecologists. Obstetricians and gynecologists record and document patient care in ways that are unique to medicine. Current electronic medical record systems are often limited in their usefulness for the practice of obstetrics and gynecology because of the absence of obstetrician-gynecologist specialty-specific requirements and functions. The Certification Commission on Health Information Technology is currently the only federally recognized body for certification of electronic medical record systems. As Certification Commission on Health Information Technology expands the certification criteria for electronic medical records, the special requirements identified in this report will be used as a framework for developing obstetrician-gynecologist specialty-specific criteria to be incorporated into the Certification Commission on Health Information Technology endorsement for electronic medical records used by obstetrician-gynecologists.

  4. The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards

    PubMed Central

    Lau, Hong Sang; Florax, Christa; Porsius, Arijan J; de Boer, Anthonius

    2000-01-01

    Aims Accurate recording of medication histories in hospital medical records (HMR) is important when patients are admitted to the hospital. Lack of registration of drugs can lead to unintended discontinuation of drugs and failure to detect drug related problems. We investigated the comprehensiveness of medication histories in HMR with regard to prescription drugs by comparing the registration of drugs in HMR with computerized pharmacy records obtained from the community pharmacy. Methods Patients admitted to the general ward of two acute care hospitals were included in the study after obtaining informed consent. We conducted an interview on drugs used just prior to hospitalization and extracted the medication history from the HMR. Pharmacy records were collected from the community pharmacists over a 1 year period before the admission. Drugs in the pharmacy records were defined as possibly used (PU-drugs) when they were dispensed before the admission date and had a theoretical enddate of 7 days before the admission date or later. If any PU-drug was not recorded in the HMR, we asked the patient whether they were using that drug or not. Results Data were obtained from 304 patients who had an average age of 71 (range 40–92) years. The total number of drugs according to the HMR was 1239, 43 of which were not used. When compared with the pharmacy records we found an extra 518 drugs that were not recorded in the HMR but were possibly in use. After verification with the patients, 410 of these were indeed in use bringing the total number of drugs in use to 1606. The type of drugs in use but not recorded in the HMR covered a broad spectrum and included many drugs considered to be important such as cardiovascular drugs (n = 67) and NSAIDs (n = 31). The percentages of patients with 0, 1, 2, 3, 4, 5–11 drugs not recorded in the HMR were 39, 28, 16, 8, 3.6 and 5.5, respectively. Of the 1606 drugs in use according to information from all sources, only 38 (2.4%) were not

  5. Security and confidentiality in an electronic medical record.

    PubMed

    Olson, L A; Peters, S G; Stewart, J B

    1998-01-01

    The maintenance of privacy and confidentially must remain a core principle of the interaction between patients and medical staff. Traditionally, the single paper copy of the medical history has been treated with systematic handling, careful tracking, and respect for the integrity and confidentiality of the contents. The widespread availability of computerized information requires that these principles be maintained in the electronic environment. Security measures should protect sensitive data without hindering medical practice. At Mayo, we have established data security policies and standards for the handling of all electronic information. Dissemination and communication of these standards and guidelines are an ongoing challenge. Technical maneuvers can be employed to protect data integrity, identify users, and monitor compliance. Personnel policies must be updated to reflect the responsibilities and liabilities of the electronic environment. Practice efficiencies and access to clinical data must be balanced by individual responsibility and accountability for privileged patient information.

  6. Reliability of medical records in diagnosing inflammatory breast cancer in Egypt.

    PubMed

    Le, Lynne; Schairer, Catherine; Hablas, Ahmed; Meza, Jane; Watanabe-Galloway, Shinobu; Ramadan, Mohamed; Merajver, Sofia D; Seifeldin, Ibrahim A; Soliman, Amr S

    2017-03-16

    Inflammatory breast cancer (IBC) is a rare, aggressive breast cancer diagnosed clinically by the presence of diffuse erythema, peau d'orange, and edema that arise quickly in the affected breast. This study evaluated the validity of medical records in Gharbiah, Egypt in identifying clinical signs/symptoms of IBC. For 34 IBC cases enrolled in a case-control study at the Gharbiah Cancer Society and Tanta Cancer Center, Egypt (2009-2010), we compared signs/symptoms of IBC noted in medical records to those recorded on a standardized form at the time of IBC diagnosis by clinicians participating in the case-control study. We calculated the sensitivity and specificity of medical records as compared to the case-control study for recording these signs/symptoms. We also performed McNemar's tests. In the case-control study, 32 (94.1%) IBC cases presented with peau d'orange, 30 (88.2%) with erythema, and 31 (91.2%) with edema. The sensitivities of the medical records as compared to the case-control study were 0.8, 0.5, and 0.2 for peau d'orange, erythema, and edema, respectively. Corresponding specificities were 1.0, 0.5, and 1.0. p values for McNemar's test were <0.05 for all signs. Medical records had data on the extent and duration of signs for at most 27% of cases for which this information was recorded in the case-control study. Twenty-three of the 34 cases (67.6%) had confirmed diagnosis of IBC in their medical records. Medical records lacked information on signs/symptoms of IBC, especially erythema and edema, when compared to the case-control study. Deficient medical records could have implications for diagnosis and treatment of IBC and proper documentation of cases in cancer registries.

  7. Implementation of an optical disk system for medical record storage.

    PubMed

    Mahoney, M E

    1990-09-01

    MARS was a joint developmental effort between Maine Medical Center and Advanced Healthcare Systems, Inc. It has taken nearly three years to get the system (hardware, software, and staff) to a point where it can now meet daily production requirements. This project was truly unique, so there was no opportunity to learn from the experiences of others. The optical disk system has been an attractive solution to some of the problems experienced at Maine Medical Center. The result was worth the effort in terms of both dollars and other less quantifiable benefits that have had a positive impact on patient care.

  8. The use of focused electronic medical record forms to improve health-care outcomes.

    PubMed

    Caldwell, Bryan D; Katz, Robert D; Pascarella, Eugene M

    2011-01-01

    We tested the use of specifically designed electronic medical record forms, thereby demonstrating the ability to electronically capture, report, and compare clinical data. To that end, podiatric physicians can determine what constitutes the most effective program or treatment for specific conditions by documenting their treatment outcomes. A prospective case series was initiated to determine the value of using focused electronic medical record forms to track walking programs in the practices of podiatric physicians. Three patients were observed for 48 weeks using focused electronic medical record forms to input data (body mass index, cholesterol level, hemoglobin A(1c) level, blood pressure, and other vital information). Patients were given pedometers so that they could log their mileage and their podiatric physicians could enter it into the medical record. Information was collected using an electronic medical record system with the ability to link multiple templates together and assign logic to create flexible entry completion requirements. The clinical data generated are captured in a common database, where the data offer future opportunity to compare statistics among a multitude of practices in various demographic regions. Focused electronic medical record forms were effectively used to track improvements and overall health benefits in a walking program supervised by podiatric physicians. Valuable information can be ascertained with focused electronic medical record forms to help determine treatment effectiveness. This information can later be compared with practices across many different demographics to ascertain the best evidence-based practice.

  9. A pilot study of the impact of an educational intervention aimed at improving medical record documentation.

    PubMed

    Farzandipour, M; Meidani, Z; Rangraz Jeddi, F; Gilasi, H; Shokrizadeh Arani, L; Fakharian, E; Saddik, B

    2013-01-01

    Studies have shown the importance of medical staff education in improving chart documentation and accuracy of medical coding. This study aimed to examine the effect of an educational intervention on recording medical diagnoses among a sample of medical residents based at Kashan University of Medical Sciences. This pilot study was conducted in 2010 and involved 19 residents in different specialties (internal medicine, obstetrics and gynecology, and surgery). Guidelines for recording diagnostic information related to surgery, obstetrics and internal medicine were taught at a five-hour lecture. Five medical records from each resident from before and after the educational intervention were assessed using a checklist based on relevant diagnostic information related to each discipline. Data were analysed using a paired t-test and Wilcoxson signed rank test. There was no improvement in the quality and accuracy of the recording of obstetric diagnoses (type, place, outcome and complications of delivery) after the training. There was also no effect on the documentation of underlying causes and clinical manifestations of disease by internal medicine and surgery residents (p=0.285 and p=0.584, respectively). The single education session did not improve recording of diagnoses among residents. The gathering and recording of complete, accurate and high quality medical records requires interaction between the hospital management, health information management professionals and healthcare providers. It is therefore essential to develop a more sophisticated portfolio of strategies that involves these key stakeholders.

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

    PubMed

    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)

  11. 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

  12. 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

  13. Records access and management on closure of a medical practice.

    PubMed

    Carter, David J

    2015-07-20

    Despite uneven regulation, health practitioners registered with the Australian Health Practitioner Regulation Agency have immediate and continuing obligations to patients when contemplating practice closure. Recent enforcement actions by regulators highlight the importance of knowledge and compliance with requirements relating to record management.

  14. Comparison of birth weight between school health records and medical birth records in Denmark: determinants of discrepancies.

    PubMed

    Jensen, Camilla Bjørn; Gamborg, Michael; Heitmann, Berit; Sørensen, Thorkild I A; Baker, Jennifer L

    2015-11-24

    To compare reported birth weight (BW) information in school health records with BW from medical birth records, and to investigate if maternal and offspring characteristics were associated with any discrepancies. Register-based cohort study. Denmark, 1973-1991. The study was based on BW recorded in the Copenhagen School Health Records Register (CSHRR) and in The Medical Birth Register (MBR). The registers were linked via the Danish personal identification number. Statistical comparisons of BW in the registers were performed using t tests, Pearson's correlation coefficients, Bland-Altman plots and κ coefficients. Odds of BW discrepancies >100 g were examined by logistic regressions. The study population included 47,534 children. From 1973 to 1979 when BW was grouped in 500 g intervals in the MBR, mean BW differed significantly between the registers. During 1979-1991 when BW was recorded in 10 and 1 g intervals, mean BW did not significantly differ between the two registers. BW from both registers was highly correlated (0.93-0.97). Odds of a BW discrepancy significantly increased with parity, the child's age at recall and by marital status (children of married women had the highest odds). Overall, BW information in school health records agreed very well with BW from medical birth records, suggesting that reports of BWs in school health records in Copenhagen, Denmark generally are valid. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  15. Case study of linking dental and medical healthcare records.

    PubMed

    Theis, Mary Kay; Reid, Robert J; Chaudhari, Monica; Newton, Katherine M; Spangler, Leslie; Grossman, David C; Inge, Ronald E

    2010-02-01

    To link the administrative data of a large dental carrier and an integrated health plan in Washington State to conduct an observational study of diabetes and periodontal disease. Evaluation of variable suitability, testing of linkage variables, and performing an n - 1 deterministic linkage strategy. We examined a variety of administrative data variables for their consistency over time and their information richness to use as matching variables. After choosing social security number, date of birth, first name, and last name, we tested their reliability as linking variables among a population with dual dental and medical insurance. Lastly, we performed four n - 1 deterministic linkage steps to obtain our study population. With a success match rate of more than 96% with the 4 test variables, we extracted the entire population who met the study criteria with the understanding that only a subset would successfully link. We linked 78,230 individuals (55.2% of the Group Health Cooperative population). Of these matches more than 50% occurred within a last name-first name-birth date deterministic match. Employer groups who provide dental-medical benefits for their employees send identical administrative data to dental and healthcare plans. The n - 1 deterministic linkage was accomplished by using a relatively straightforward approach because these data were fairly homogeneous and of high quality. Until medical care and dental care are integrated, it is possible to link these data to assess the impact of oral disease on overall health.

  16. Medication Records in the Emergency Department: Agreement Between Paper-Based Charts and Automated Dispensing Device

    PubMed Central

    Wing, Andrew; Hill-Taylor, Barbara; Sketris, Ingrid; Smith, Jeanne; Stewart, Sam; Hurley, Katrina F

    2012-01-01

    Background: Research exploring the agreement between traditional medication records and electronic records generated by an automated dispensing device has been limited. Objective: To evaluate the extent of agreement between medication administration records written in paper-based emergency department charts and records generated by an automated dispensing device with regard to the presence or absence of a single, prespecified medication. Methods: Medication administration records in paper-based emergency department charts and medication dispensation records generated by an automated dispensing device were evaluated for concordance. The primary outcome measure was agreement between the 2 sources with regard to the presence or absence of a record for salbutamol by metered-dose inhaler (MDI) for randomly selected patients who presented to a pediatric emergency department with wheeze-related illness from January 1, 2008, to December 31, 2009. Results: In total, 1172 patient visits met the inclusion criteria. Of these, records for 1013 visits showed agreement between the paper-based emergency department chart and the dispensation record of the automated dispensing device (kappa = 0.71, 95% confidence interval 0.67–0.75). This value did not meet the target kappa of 0.80. Stratification by time of day, day of week, month, season, or year of presentation at triage or by triage level or disposition (whether or not the patient was admitted to the hospital ward) did not significantly affect the level of agreement between the 2 sources. Conclusions: Agreement between records of salbutamol MDI administration in paper-based charts and dispensation records from an automated dispensing device was substantial, but discrepancies were present. There are significant quality management, legal, clinical, and research reasons to strive for concordance between multiple records with respect to medication use in the emergency department. Data generated by automated dispensing devices have

  17. Patient experiences with electronic medical records: Lessons learned

    PubMed Central

    Rose, Dale; Richter, Louiseann T; Kapustin, Jane

    2014-01-01

    Purpose To describe the lived experience of patients communicating with their nurse practitioners and physicians while using paper health records (PHRs) and electronic health records (EHRs) in the examination rooms. The significance of the study lies in the salience of communication between the patient and provider in promoting optimal clinical outcomes and the highest level of patient satisfaction. Data sources The study used a qualitative, phenomenological design. Audio-taped focus group interviews were conducted with 21 patients from a diabetes clinic in Baltimore, Maryland. Patients had visits with the provider before and after implementation of EHRs in the clinic. Conclusions The four themes that emerged from the three focus groups included communication issues, patient preferences for electronic records, safety and security concerns, and transition problems with implementation of EHRs. Implications for practice Potential benefits for nurse practitioners implementing the recommendations in this study include enhanced communication between patients and providers while using EHRs, increased patient satisfaction, higher levels of nurse practitioner and physician satisfaction, and avoidance of communication issues during implementation of EHR systems. PMID:25234112

  18. A software system to collect expert relevance ratings of medical record items for specific clinical tasks.

    PubMed

    Harvey, H Benjamin; Krishnaraj, Arun; Alkasab, Tarik K

    2014-02-28

    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.

  19. Can multilingual machine translation help make medical record content more comprehensible to patients?

    PubMed

    Zeng-Treitler, Qing; Kim, Hyeoneui; Rosemblat, Graciela; Keselman, Alla

    2010-01-01

    With the development of electronic personal health records, more patients are gaining access to their own medical records. However, comprehension of medical record content remains difficult for many patients. Because each record is unique, it is also prohibitively costly to employ human translators to solve this problem. In this study, we investigated whether multilingual machine translation could help make medical record content more comprehensible to patients who lack proficiency in the language of the records. We used a popular general-purpose machine translation tool called Babel Fish to translate 213 medical record sentences from English into Spanish, Chinese, Russian and Korean. We evaluated the comprehensibility and accuracy of the translation. The text characteristics of the incorrectly translated sentences were also analyzed. In each language, the majority of the translations were incomprehensible (76% to 92%) and/or incorrect (77% to 89%). The main causes of the translation are vocabulary difficulty and syntactical complexity. A general-purpose machine translation tool like the Babel Fish is not adequate for the translation of medical records; however, a machine translation tool can potentially be improved significantly, if it is trained to target certain narrow domains in medicine.

  20. 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…

  1. Performance evaluation of medical records departments by analytical hierarchy process (AHP) approach in the selected hospitals in Isfahan : medical records dep. & AHP.

    PubMed

    Ajami, Sima; Ketabi, Saeedeh

    2012-06-01

    Medical Records Department (MRD) is an important unit for evaluating and planning of care services. The goal of this study is evaluating the performance of the Medical Records Departments (MRDs) of the selected hospitals in Isfahan, Iran by using Analytical Hierarchy Process (AHP). This was an analytic of cross-sectional study that was done in spring 2008 in Isfahan, Iran. The statistical population consisted of MRDs of Alzahra, Kashani and Khorshid Hospitals in Isfahan. Data were collected by forms and through brainstorm technique. To analyze and perform AHP, Expert Choice software was used by researchers. Results were showed archiving unit has received the largest importance weight with respect to information management. However, on customer aspect admission unit has received the largest weight. Ordering weights of Medical Records Departments' Alzahra, Kashani and Khorshid Hospitals in Isfahan were with 0.394, 0.342 and 0.264 respectively. It is useful for managers to allocate and prioritize resources according to AHP technique for ranking at the Medical Records Departments.

  2. 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…

  3. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... abuse treatment, abortion, and birth control. If you manage medical records, learn the local laws and... (overseas), the age of majority is 18. Unless parents or guardians have a court order granting access or the...

  4. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... abuse treatment, abortion, and birth control. If you manage medical records, learn the local laws and... (overseas), the age of majority is 18. Unless parents or guardians have a court order granting access or the...

  5. Method for developing national quality indicators based on manual data extraction from medical records

    PubMed Central

    Couralet, Melanie; Leleu, Henri; Capuano, Frederic; Marcotte, Leah; Nitenberg, Gérard; Sicotte, Claude; Minvielle, Etienne

    2013-01-01

    Developing quality indicators (QI) for national purposes (eg, public disclosure, paying-for-performance) highlights the need to find accessible and reliable data sources for collecting standardised data. The most accurate and reliable data source for collecting clinical and organisational information still remains the medical record. Data collection from electronic medical records (EMR) would be far less burdensome than from paper medical records (PMR). However, the development of EMRs is costly and has suffered from low rates of adoption and barriers of usability even in developed countries. Currently, methods for producing national QIs based on the medical record rely on manual extraction from PMRs. We propose and illustrate such a method. These QIs display feasibility, reliability and discriminative power, and can be used to compare hospitals. They have been implemented nationwide in France since 2006. The method used to develop these QIs could be adapted for use in large-scale programmes of hospital regulation in other, including developing, countries. PMID:23015098

  6. 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

  7. 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.

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

    PubMed

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

    2014-08-01

    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. Survey. 100 veterinarians. 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]). 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. 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.

  9. ClinicalCodes: An Online Clinical Codes Repository to Improve the Validity and Reproducibility of Research Using Electronic Medical Records

    PubMed Central

    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

  10. 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.

  11. GENTIC: a computerized medical genetic case record system.

    PubMed

    Aymé, S; Aurran, Y; Gouvernet, J; Mattei, J F; Giraud, F

    1982-01-01

    Gentic is a computerized system for the storage, recall, and analysis of data collected by the Medical Genetics Center in Marseille, France. It is based on a standard case report file that includes a full clinical description of all patients, results of cytogenetic investigations, and details of the genetic counseling provided. GENTIC has been used since 1975, and data on more than 5,000 families are accessible for study. This system has improved the quality of consultations, follow-up, and research. It provides data for epidemiological studies and for syndrome identification. This system is maintained at an annual cost of $3,000, salary costs not included, after an initial investment of $40,000.

  12. 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

  13. From medical record to patient record through electronic data interchange (EDI).

    PubMed

    Kinkhorst, O M; Lalleman, A W; Hasman, A

    1996-07-01

    In this contribution the role of Electronic Data Interchange (EDI) for patient records is discussed. It is our opinion that unlimited access to patient records of different care provides is not a wise thing to do and may even not be acceptable legally. The exchange of EDI messages may be a solution in that the relevant information is exchanged on a need to know basis under the responsibility of the care provider that generated the information. The state of the art with respect to the availability of EDI messages in Europe is presented.

  14. The Effect of Educational Intervention on Medical Diagnosis Recording among Residents

    PubMed Central

    Davaridolatabadi, Nasrin; Sadoughi, Farahnaz; Meidani, Zahra; Shahi, Mehraban

    2013-01-01

    Introduction: Studies indicate that using interventions including education may improve medical record documentation and decrease incomplete files. Since physicians play a crucial role in medical record documentation, the researchers intend to examine the effect of educational intervention on physicians’ performance and knowledge about principles of medical diagnosis recording among residents in Hormozgan University of Medical Sciences(HUMS). Methods: This quasi-experimental study was conducted in 2010 on 40 specialty residents (from internal medicine, obstetrics and gynecology, pediatrics, anesthesiology and surgery specialties) in Hormozgan University of Medical Sciences. During a workshop, guidelines for recording diagnostic information related to given specialty were taught. Before and after the intervention, five medical records from each resident were selected to assess physician performance about chart documentation. Using a questionnaire, physicians’ knowledge was investigated before and after intervention. Data were analyzed through one-way ANOVA test. Results: Change in physicians’ knowledge before and after education was not statistically significant (p = 0.15). Residents’ behavior did not have statistically significant changes during three phases of the study. Conclusion: Diversity of related factors which contributes to the quality of documentation compels portfolio of strategies to enhance medical charting. Employing combination of best practice efforts including educating physicians from the beginning of internship and applying targeted strategy focus on problematic areas and existing gap may enhance physicians’ behavior about chart documentation. PMID:24167386

  15. 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.

  16. A Study to Delineate Roles and Functions of Medical Record Personnel: Final Report.

    ERIC Educational Resources Information Center

    American Medical Record Association, Chicago, IL.

    In order to be able to comply, and to be able to document their compliance, with federal legislation regarding health occupations education and discriminatory practices, the American Medical Record Association conducted a study to see if a data base could be built to validate proficiency tests for medical personnel. The report was prepared to…

  17. 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…

  18. The patient's photograph in the medical record as a diagnostic tool.

    PubMed

    Golan-Cohen, Avivit; Horn, Oded; Sive, Philip H; Vinker, Shlomo

    2008-12-01

    Two case reports are presented: one of acromegaly and the other of hyperthyroidism. Previous photographs of the patients that appeared in their military medical record were of considerable assistance in making the correct diagnoses. When "smart cards" are issued in the future, inclusion of a photograph as an integral part of the patient's medical information should be considered.

  19. 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..., underscores our need to process cases more efficiently by using advanced technologies. Applicants for... benefits. We rely on medical providers such as doctors, hospitals, clinics, and others in the healthcare...

  20. 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…

  1. 33 CFR 150.604 - Who controls access to medical monitoring and exposure records?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 33 Navigation and Navigable Waters 2 2013-07-01 2013-07-01 false Who controls access to medical monitoring and exposure records? 150.604 Section 150.604 Navigation and Navigable Waters COAST GUARD... Health Safety and Health (general) § 150.604 Who controls access to medical monitoring and...

  2. Optimizing Inpatient Urine Culture Ordering Practices Using the Electronic Medical Record: A Pilot Study.

    PubMed

    Shirley, Daniel; Scholtz, Harry; Osterby, Kurt; Musuuza, Jackson; Fox, Barry; Safdar, Nasia

    2017-04-01

    A prospective quasi-experimental before-and-after study of an electronic medical record-anchored intervention of embedded education on appropriate urine culture indications and indication selection reduced the number of urine cultures ordered for catheterized patients at an academic medical center. This intervention could be a component of CAUTI-reduction bundles. Infect Control Hosp Epidemiol 2017;38:486-488.

  3. 29 CFR 1904.9 - Recording criteria for cases involving medical removal under OSHA standards.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... under OSHA standards. 1904.9 Section 1904.9 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL... removal under OSHA standards. (a) Basic requirement. If an employee is medically removed under the medical surveillance requirements of an OSHA standard, you must record the case on the OSHA 300 Log. (b) Implementation...

  4. 29 CFR 1904.9 - Recording criteria for cases involving medical removal under OSHA standards.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... under OSHA standards. 1904.9 Section 1904.9 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL... removal under OSHA standards. (a) Basic requirement. If an employee is medically removed under the medical surveillance requirements of an OSHA standard, you must record the case on the OSHA 300 Log. (b) Implementation...

  5. 29 CFR 1904.9 - Recording criteria for cases involving medical removal under OSHA standards.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... under OSHA standards. 1904.9 Section 1904.9 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL... removal under OSHA standards. (a) Basic requirement. If an employee is medically removed under the medical surveillance requirements of an OSHA standard, you must record the case on the OSHA 300 Log. (b) Implementation...

  6. 29 CFR 1904.9 - Recording criteria for cases involving medical removal under OSHA standards.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 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...

  7. 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...

  8. 78 FR 55114 - Access to Employee Exposure and Medical Records; Extension of the Office of Management and Budget...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-09

    ... Occupational Safety and Health Administration Access to Employee Exposure and Medical Records; Extension of the... Exposure and Medical Records Standard (29 CFR 1910.1020). DATES: Comments must be submitted (postmarked... to employee exposure monitoring data and medical records. This regulation does not require...

  9. Inferring Clinical Workflow Efficiency via Electronic Medical Record Utilization

    PubMed Central

    Chen, You; Xie, Wei; Gunter, Carl A; Liebovitz, David; Mehrotra, Sanjay; Zhang, He; Malin, Bradley

    2015-01-01

    Complexity in clinical workflows can lead to inefficiency in making diagnoses, ineffectiveness of treatment plans and uninformed management of healthcare organizations (HCOs). Traditional strategies to manage workflow complexity are based on measuring the gaps between workflows defined by HCO administrators and the actual processes followed by staff in the clinic. However, existing methods tend to neglect the influences of EMR systems on the utilization of workflows, which could be leveraged to optimize workflows facilitated through the EMR. In this paper, we introduce a framework to infer clinical workflows through the utilization of an EMR and show how such workflows roughly partition into four types according to their efficiency. Our framework infers workflows at several levels of granularity through data mining technologies. We study four months of EMR event logs from a large medical center, including 16,569 inpatient stays, and illustrate that over approximately 95% of workflows are efficient and that 80% of patients are on such workflows. At the same time, we show that the remaining 5% of workflows may be inefficient due to a variety of factors, such as complex patients. PMID:26958173

  10. Inferring Clinical Workflow Efficiency via Electronic Medical Record Utilization.

    PubMed

    Chen, You; Xie, Wei; Gunter, Carl A; Liebovitz, David; Mehrotra, Sanjay; Zhang, He; Malin, Bradley

    Complexity in clinical workflows can lead to inefficiency in making diagnoses, ineffectiveness of treatment plans and uninformed management of healthcare organizations (HCOs). Traditional strategies to manage workflow complexity are based on measuring the gaps between workflows defined by HCO administrators and the actual processes followed by staff in the clinic. However, existing methods tend to neglect the influences of EMR systems on the utilization of workflows, which could be leveraged to optimize workflows facilitated through the EMR. In this paper, we introduce a framework to infer clinical workflows through the utilization of an EMR and show how such workflows roughly partition into four types according to their efficiency. Our framework infers workflows at several levels of granularity through data mining technologies. We study four months of EMR event logs from a large medical center, including 16,569 inpatient stays, and illustrate that over approximately 95% of workflows are efficient and that 80% of patients are on such workflows. At the same time, we show that the remaining 5% of workflows may be inefficient due to a variety of factors, such as complex patients.

  11. 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

  12. 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…

  13. 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.

  14. 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.

  15. [Pregnant Cards information and medical records of primary care on prenatal care].

    PubMed

    Polgliani, Rúbia Bastos Soares; Dos Santos Neto, Edson Theodoro; Zandonade, Eliana

    2014-06-01

    To determine the agreement between the information on pregnant cards and on primary care medical records about prenatal assistance in the city of Vitória, Espírito Santo, Brazil. A population study of 360 puerperal women living in this city was interviewed at three hospitals where the cards were copied. Prenatal care data were collected by reviewing the medical records at the city health unit. The information was collected, processed, and submitted to Kappa, Adjusted Kappa, and McNemar tests to check agreement and tendency to disagreement between the cards and the medical records. The levels of agreement within prenatal care were predominantly moderate (Kappa=0.4-0.6). There was a higher tendency to keep records of appointments on the cards (McNemar=22.3; p-value<0.01). Records of supplementation with folic acid and ferrous sulphate were kept more often on the medical records (McNemar=70.8 and 69.8, respectively; p-value<0.01). The tetanus vaccination coverage was about 50%. Clinical and obstetric procedures and laboratory tests were primarily recorded on the card. The medical records of primary care were underused as a tool for communication among health professionals, highlighting a precarious record keeping. The results suggest that thought be given to guarantee that the minimum procedures established by the Guidelines of Maternal and Infant Health are followed, and also to the importance of clinical record keeping in health services, since there is variation depending on the source of information.

  16. Pathology Report: Presacral Noncommunicating Enteric Duplication Cyst.

    PubMed

    Seydafkan, Shabnam; Shibata, David; Sanchez, Julian; Tran, Nam D; Leon, Marino; Coppola, Domenico

    2016-04-01

    Gastrointestinal (GI) tract duplication cysts or enteric duplication cysts are rare congenital malformations sometimes found on the mesenteric aspect of segments of the alimentary tract. Enteric duplication cysts are lined by normal GI epithelium and may be classified as foregut, mid-gut, and hindgut cysts. Except in very rare cases of retroperitoneal enteric duplication cysts, these cysts communicate with the GI tract and share a common blood supply. Concurrent congenital malformations are not uncommon and malignant transformation within enteric duplication cysts has also been reported. We describe a case of a noncommunicating enteric duplication cyst in a 52-year-old woman. The patient presented with a presacral cystic mass requiring frequent drainage procedures that was primarily believed to be of neural origin. Upon resection, the lesion contained heterotopic tissue, including ciliated bronchial epithelium, squamous and transitional epithelia, and pancreatic and gastric tissue. Focal, low-grade intestinal adenoma was present, but malignancy was not detected in this case. To our knowledge, this is the sixth reported case of a noncommunicating enteric duplication cyst in the English medical literature.

  17. 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.

  18. 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.

  19. Extracting Concepts Related to Homelessness from the Free Text of VA Electronic Medical Records.

    PubMed

    Gundlapalli, Adi V; Carter, Marjorie E; Divita, Guy; Shen, Shuying; Palmer, Miland; South, Brett; Durgahee, B S Begum; Redd, Andrew; Samore, Matthew

    2014-01-01

    Mining the free text of electronic medical records (EMR) using natural language processing (NLP) is an effective method of extracting information not always captured in administrative data. We sought to determine if concepts related to homelessness, a non-medical condition, were amenable to extraction from the EMR of Veterans Affairs (VA) medical records. As there were no off-the-shelf products, a lexicon of terms related to homelessness was created. A corpus of free text documents from outpatient encounters was reviewed to create the reference standard for NLP training and testing. V3NLP Framework was used to detect instances of lexical terms and was compared to the reference standard. With a positive predictive value of 77% for extracting relevant concepts, this study demonstrates the feasibility of extracting positively asserted concepts related to homelessness from the free text of medical records.

  20. 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.

  1. Extracting Concepts Related to Homelessness from the Free Text of VA Electronic Medical Records

    PubMed Central

    Gundlapalli, Adi V.; Carter, Marjorie E.; Divita, Guy; Shen, Shuying; Palmer, Miland; South, Brett; Durgahee, B.S. Begum; Redd, Andrew; Samore, Matthew

    2014-01-01

    Mining the free text of electronic medical records (EMR) using natural language processing (NLP) is an effective method of extracting information not always captured in administrative data. We sought to determine if concepts related to homelessness, a non-medical condition, were amenable to extraction from the EMR of Veterans Affairs (VA) medical records. As there were no off-the-shelf products, a lexicon of terms related to homelessness was created. A corpus of free text documents from outpatient encounters was reviewed to create the reference standard for NLP training and testing. V3NLP Framework was used to detect instances of lexical terms and was compared to the reference standard. With a positive predictive value of 77% for extracting relevant concepts, this study demonstrates the feasibility of extracting positively asserted concepts related to homelessness from the free text of medical records. PMID:25954364

  2. Architecture of portable electronic medical records system integrated with streaming media.

    PubMed

    Chen, Wei; Shih, Chien-Chou

    2012-02-01

    Due to increasing occurrence of accidents and illness during business trips, travel, or overseas studies, the requirement for portable EMR (Electronic Medical Records) has increased. This study proposes integrating streaming media technology into the EMR system to facilitate referrals, contracted laboratories, and disease notification among hospitals. The current study encoded static and dynamic medical images of patients into a streaming video format and stored them in a Flash Media Server (FMS). Based on the Taiwan Electronic Medical Record Template (TMT) standard, EMR records can be converted into XML documents and used to integrate description fields with embedded streaming videos. This investigation implemented a web-based portable EMR interchanging system using streaming media techniques to expedite exchanging medical image information among hospitals. The proposed architecture of the portable EMR retrieval system not only provides local hospital users the ability to acquire EMR text files from a previous hospital, but also helps access static and dynamic medical images as reference for clinical diagnosis and treatment. The proposed method protects property rights of medical images through information security mechanisms of the Medical Record Interchange Service Center and Health Certificate Authorization to facilitate proper, efficient, and continuous treatment of patients.

  3. Instructional analysis of lecture video recordings and its application for quality improvement of medical lectures.

    PubMed

    Baek, Sunyong; Im, Sun Ju; Lee, Sun Hee; Kam, Beesung; Yune, So Joung; Lee, Sang Soo; Lee, Jung A; Lee, Yuna; Lee, Sang Yeoup

    2011-12-01

    The lecture is a technique for delivering knowledge and information cost-effectively to large medical classes in medical education. The aim of this study was to analyze teaching quality, based on triangle analysis of video recordings of medical lectures, to strengthen teaching competency in medical school. The subjects of this study were 13 medical professors who taught 1st- and 2nd-year medical students and agreed to a triangle analysis of video recordings of their lectures. We first performed triangle analysis, which consisted of a professional analysis of video recordings, self-assessment by teaching professors, and feedback from students, and the data were crosschecked by five school consultants for reliability and consistency. Most of the distress that teachers experienced during the lecture occurred in uniform teaching environments, such as larger lecture classes. Larger lectures that primarily used PowerPoint as a medium to deliver information effected poor interaction with students. Other distressing factors in the lecture were personal characteristics and lack of strategic faculty development. Triangle analysis of video recordings of medical lectures gives teachers an opportunity and motive to improve teaching quality. Faculty development and various improvement strategies, based on this analysis, are expected to help teachers succeed as effective, efficient, and attractive lecturers while improving the quality of larger lecture classes.

  4. Medical student database development: a model for record management in a multi-departmental setting.

    PubMed Central

    Vercillo, D. M.; Holmes, K. C.; Pingree, M. J.; Bray, B. E.; Lincoln, M. J.

    1999-01-01

    Student records flow through medical school offices at a rapid rate. Much of this data is often tracked on paper, spread across multiple departments. The Medical Student Informatics Group at the University of Utah School of Medicine identified offices and organizations documenting student information. We assessed departmental needs, identified records, and researched database software available within the private sector and academic community. Although a host of database applications exist, few publications discuss database models for storage and retrieval of student records. We developed and deployed an Internet based application to meet current requirements, and allow for future expandability. During a test period, users were polled regarding utility, security, stability, ease of use, data accuracy, and potential project expansion. Feedback demonstrated widespread approval, and considerable interest in additional feature development. This experience suggests that many medical schools would benefit from centralized database management of student records. Images Figure 3 Figure 4 Figure 5 PMID:10566507

  5. 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.

  6. Doctors' use of electronic medical records systems in hospitals: cross sectional survey

    PubMed Central

    Lærum, Hallvard; Ellingsen, Gunnar; Faxvaag, Arild

    2001-01-01

    Objectives To compare the use of three electronic medical records systems by doctors in Norwegian hospitals for general clinical tasks. Design Cross sectional questionnaire survey. Semistructured telephone interviews with key staff in information technology in each hospital for details of local implementation of the systems. Setting 32 hospital units in 19 Norwegian hospitals with electronic medical records systems. Participants 227 (72%) of 314 hospital doctors responded, equally distributed between the three electronic medical records systems. Main outcome measures Proportion of respondents who used the electronic system, calculated for each of 23 tasks; difference in proportions of users of different systems when functionality of systems was similar. Results Most tasks listed in the questionnaire (15/23) were generally covered with implemented functions in the electronic medical records systems. However, the systems were used for only 2-7 of the tasks, mainly associated with reading patient data. Respondents showed significant differences in frequency of use of the different systems for four tasks for which the systems offered equivalent functionality. The respondents scored highly in computer literacy (72.2/100), and computer use showed no correlation with respondents' age, sex, or work position. User satisfaction scores were generally positive (67.2/100), with some difference between the systems. Conclusions Doctors used electronic medical records systems for far fewer tasks than the systems supported. What is already known on this topicElectronic information systems in health care have not undergone systematic evaluation, and few comparisons between electronic medical records systems have been madeGiven the information intensive nature of clinical work, electronic medical records systems should be of help to doctors for most clinical tasksWhat this study addsDoctors in Norwegian hospitals reported a low level of use of all electronic medical records systems

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

    PubMed

    Seo, Hwa Jeong; Kim, Hye Hyeon; Kim, Ju Han

    2011-09-01

    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. 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. 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. 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.

  8. The concordance between self-reported medication use and pharmacy records in pregnant women.

    PubMed

    Cheung, K; El Marroun, H; Elfrink, M E; Jaddoe, V W V; Visser, L E; Stricker, B H Ch

    2017-09-01

    Several studies have been conducted to assess determinants affecting the performance or accuracy of self-reports. These studies are often not focused on pregnant women, or medical records were used as a data source where it is unclear if medications have been dispensed. Therefore, our objective was to evaluate the concordance between self-reported medication data and pharmacy records among pregnant women and its determinants. We conducted a population-based cohort study within the Generation R study, in 2637 pregnant women. The concordance between self-reported medication data and pharmacy records was calculated for different therapeutic classes using Yule's Y. We evaluated a number of variables as determinant of discordance between both sources through univariate and multivariate logistic regression analysis. The concordance between self-reports and pharmacy records was moderate to good for medications used for chronic conditions, such as selective serotonin reuptake inhibitors or anti-asthmatic medications (0.88 and 0.68, respectively). Medications that are used occasionally, such as antibiotics, had a lower concordance (0.51). Women with a Turkish or other non-Western background were more likely to demonstrate discordance between pharmacy records and self-reported data compared with women with a Dutch background (Turkish: odds ratio, 1.63; 95% confidence interval, 1.16-2.29; other non-Western: odds ratio, 1.33; 95% confidence interval, 1.03-1.71). Further research is needed to assess how the cultural or ethnic differences may affect the concordance or discordance between both medication sources. The results of this study showed that the use of multiple sources is needed to have a good estimation of the medication use during pregnancy. Copyright © 2017 John Wiley & Sons, Ltd.

  9. Effects and Satisfaction of Medical Device Safety Information Reporting System Using Electronic Medical Record.

    PubMed

    Jang, Hye Jung; Choi, Young Deuk; Kim, Nam Hyun

    2017-04-01

    This paper describes an evaluation study on the effectiveness of developing an in-hospital medical device safety information reporting system for managing safety information, including adverse incident data related to medical devices, following the enactment of the Medical Device Act in Korea. Medical device safety information reports were analyzed for 190 cases that took place prior to the application of a medical device safety information reporting system and during a period when the reporting system was used. Also, questionnaires were used to measure the effectiveness of the medical device safety information reporting system. The analysis was based on the questionnaire responses of 15 reporters who submitted reports in both the pre- and post-reporting system periods. Sixty-two reports were submitted in paper form, but after the system was set up, this number more than doubled to 128 reports in electronic form. In terms of itemized reporting, a total of 45 items were reported. Before the system was used, 23 items had been reported, but this increased to 32 items after the system was put to use. All survey variables of satisfaction received a mean of over 3 points, while positive attitude, potential benefits, and positive benefits all exceeded 4 points, each receiving 4.20, 4.20, and 4.13, respectively. Among the variables, time-consuming and decision-making had the lowest mean values, each receiving 3.53. Satisfaction was found to be high for system quality and user satisfaction, but relatively low for time-consuming and decision-making. We were able to verify that effective reporting and monitoring of adverse incidents and the safety of medical devices can be implemented through the establishment of an in-hospital medical device safety information reporting system that can enhance patient safety and medical device risk management.

  10. Effects and Satisfaction of Medical Device Safety Information Reporting System Using Electronic Medical Record

    PubMed Central

    Jang, Hye Jung; Choi, Young Deuk

    2017-01-01

    Objectives This paper describes an evaluation study on the effectiveness of developing an in-hospital medical device safety information reporting system for managing safety information, including adverse incident data related to medical devices, following the enactment of the Medical Device Act in Korea. Methods Medical device safety information reports were analyzed for 190 cases that took place prior to the application of a medical device safety information reporting system and during a period when the reporting system was used. Also, questionnaires were used to measure the effectiveness of the medical device safety information reporting system. The analysis was based on the questionnaire responses of 15 reporters who submitted reports in both the pre- and post-reporting system periods. Results Sixty-two reports were submitted in paper form, but after the system was set up, this number more than doubled to 128 reports in electronic form. In terms of itemized reporting, a total of 45 items were reported. Before the system was used, 23 items had been reported, but this increased to 32 items after the system was put to use. All survey variables of satisfaction received a mean of over 3 points, while positive attitude, potential benefits, and positive benefits all exceeded 4 points, each receiving 4.20, 4.20, and 4.13, respectively. Among the variables, time-consuming and decision-making had the lowest mean values, each receiving 3.53. Satisfaction was found to be high for system quality and user satisfaction, but relatively low for time-consuming and decision-making. Conclusions We were able to verify that effective reporting and monitoring of adverse incidents and the safety of medical devices can be implemented through the establishment of an in-hospital medical device safety information reporting system that can enhance patient safety and medical device risk management. PMID:28523207

  11. [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.

  12. Medical device integration: CIOs must bridge the digital divide between devices and electronic medical records.

    PubMed

    Raths, David

    2009-02-01

    To get funding approved for medical device integration, ClOs suggest focusing on specific patient safety or staff efficiency pain points. Organizations that make clinical engineering part of their IT team report fewer chain-of-command issues. It also helps IT people understand the clinical goals because the engineering people have been working closely with clinicians for years. A new organization has formed to work on collaboration between clinical engineers and IT professionals. For more information, go to www.ceitcollaboration.org. ECRI Institute has written a guide to handling the convergence of medical technology and hospital networks. Its "Medical Technology for the IT Professional: An Essential Guide for Working in Today's Healthcare Setting" also details how IT professionals can assist hospital technology planning and acquisition, and provide ongoing support for IT-based medical technologies. For more information, visit www.ecri.org/ITresource.

  13. Agreement between maternal interview- and medical record-based gestational age.

    PubMed

    Hakim, R B; Tielsch, J M; See, L C

    1992-09-01

    Agreement between maternal interview- and medical record-based gestational age was assessed by using data from a case-control study of childhood strabismus. The sample consisted of 383 cases of strabismus and their age-matched controls, diagnosed between 1985 and 1986 in Baltimore, Maryland, who were under age 7 years when diagnosed. Medical record-based gestational age was derived, in order of priority, from early ultrasound examination, time from the last menstrual period, pediatric examination, and obstetric examination. The intraclass correlation coefficient, kappa, and mean difference were used to compare agreement between maternal interview- and medical record-based gestational age by maternal and pregnancy characteristics and characteristics related to study design. Overall, 86 percent of mothers were within 2 weeks of the gestational age reported in the medical record. The intraclass correlation coefficient comparing maternal and medical record-based gestational age was 0.83 (95% confidence interval 0.80-0.86). Agreement was positively associated with shorter length of recall, low birth order, and having a neonatal illness related to prematurity. Agreement was poor among mothers of healthy preterm infants. There was a weak positive association between recall and some sociodemographic covariates. There was greater misclassification of prematurity in the controls than in the cases. The results suggest that, in general, women recall gestational age well, which supports the use of gestational age derived from maternal interviews.

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

    PubMed

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

    2010-10-01

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

  15. A cost-benefit analysis of electronic medical records in primary care.

    PubMed

    Wang, Samuel J; Middleton, Blackford; Prosser, Lisa A; Bardon, Christiana G; Spurr, Cynthia D; Carchidi, Patricia J; Kittler, Anne F; Goldszer, Robert C; Fairchild, David G; Sussman, Andrew J; Kuperman, Gilad J; Bates, David W

    2003-04-01

    Electronic medical record systems improve the quality of patient care and decrease medical errors, but their financial effects have not been as well documented. The purpose of this study was to estimate the net financial benefit or cost of implementing electronic medical record systems in primary care. We performed a cost-benefit study to analyze the financial effects of electronic medical record systems in ambulatory primary care settings from the perspective of the health care organization. Data were obtained from studies at our institution and from the published literature. The reference strategy for comparisons was the traditional paper-based medical record. The primary outcome measure was the net financial benefit or cost per primary care physician for a 5-year period. The estimated net benefit from using an electronic medical record for a 5-year period was 86,400 US dollars per provider. Benefits accrue primarily from savings in drug expenditures, improved utilization of radiology tests, better capture of charges, and decreased billing errors. In one-way sensitivity analyses, the model was most sensitive to the proportion of patients whose care was capitated; the net benefit varied from a low of 8400 US dollars to a high of 140,100 US dollars . A five-way sensitivity analysis with the most pessimistic and optimistic assumptions showed results ranging from a 2300 US dollars net cost to a 330,900 US dollars net benefit. Implementation of an electronic medical record system in primary care can result in a positive financial return on investment to the health care organization. The magnitude of the return is sensitive to several key factors. Copyright 2003 by Excerpta Medica Inc.

  16. 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%.

  17. 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.

  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. 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

  20. Attitudes toward inter-hospital electronic patient record exchange: discrepancies among physicians, medical record staff, and patients.

    PubMed

    Wang, Jong-Yi; Ho, Hsiao-Yun; Chen, Jen-De; Chai, Sinkuo; Tai, Chih-Jaan; Chen, Yung-Fu

    2015-07-12

    In this era of ubiquitous information, patient record exchange among hospitals still has technological and individual barriers including resistance to information sharing. Most research on user attitudes has been limited to one type of user or aspect. Because few analyses of attitudes toward electronic patient records (EPRs) have been conducted, understanding the attitudes among different users in multiple aspects is crucial to user acceptance. This proof-of-concept study investigated the attitudes of users toward the inter-hospital EPR exchange system implemented nationwide and focused on discrepant behavioral intentions among three user groups. The system was designed by combining a Health Level 7-based protocol, object-relational mapping, and other medical informatics techniques to ensure interoperability in realizing patient-centered practices. After implementation, three user-specific questionnaires for physicians, medical record staff, and patients were administered, with a 70 % response rate. The instrument showed favorable convergent construct validity and internal consistency reliability. Two dependent variables were applied: the attitudes toward privacy and support. Independent variables comprised personal characteristics, work characteristics, human aspects, and technology aspects. Major statistical methods included exploratory factor analysis and general linear model. The results from 379 respondents indicated that the patients highly agreed with privacy protection by their consent and support for EPRs, whereas the physicians remained conservative toward both. Medical record staff was ranked in the middle among the three groups. The three user groups demonstrated discrepant intentions toward privacy protection and support. Experience of computer use, level of concerns, usefulness of functions, and specifically, reason to use electronic medical records and number of outpatient visits were significantly associated with the perceptions. Overall, four