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Sample records for medical record protection

  1. Your Medical Records

    Science.gov (United States)

    ... 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 ...

  2. Surgical medical record

    DEFF Research Database (Denmark)

    Bulow, S.

    2008-01-01

    A medical record is presented on the basis of selected linguistic pearls collected over the years from surgical case records Udgivelsesdato: 2008/12/15......A medical record is presented on the basis of selected linguistic pearls collected over the years from surgical case records Udgivelsesdato: 2008/12/15...

  3. 32 CFR 701.122 - Medical records.

    Science.gov (United States)

    2010-07-01

    ... 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...

  4. Your Medical Records

    Science.gov (United States)

    ... family doctor. When it comes to asking for medical records, different health care providers have different ways of doing things. Some might ... are needed faster — like when a patient needs medical treatment — the health care provider holding the records usually releases them immediately. If ...

  5. How can hospitals better protect the privacy of electronic medical records? Perspectives from staff members of health information management departments.

    Science.gov (United States)

    Sher, Ming-Ling; Talley, Paul C; Cheng, Tain-Junn; Kuo, Kuang-Ming

    2017-05-01

    The adoption of electronic medical records (EMR) is expected to better improve overall healthcare quality and to offset the financial pressure of excessive administrative burden. However, safeguarding EMR against potentially hostile security breaches from both inside and outside healthcare facilities has created increased patients' privacy concerns from all sides. The aim of our study was to examine the influencing factors of privacy protection for EMR by healthcare professionals. We used survey methodology to collect questionnaire responses from staff members in health information management departments among nine Taiwanese hospitals active in EMR utilisation. A total of 209 valid responses were collected in 2014. We used partial least squares for analysing the collected data. Perceived benefits, perceived barriers, self-efficacy and cues to action were found to have a significant association with intention to protect EMR privacy, while perceived susceptibility and perceived severity were not. Based on the findings obtained, we suggest that hospitals should provide continuous ethics awareness training to relevant staff and design more effective strategies for improving the protection of EMR privacy in their charge. Further practical and research implications are also discussed.

  6. Medical records and access thereto.

    Science.gov (United States)

    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.

  7. Medical Secretaries’ Care of Records

    DEFF Research Database (Denmark)

    Bossen, Claus; Jensen, Lotte Groth; Witt, Flemming

    2012-01-01

    We describe the cooperative work of medical secretaries at two hospital departments, during the implementation of an electronic health record system. Medical secretaries' core task is to take care of patient records by ensuring that also do information gatekeeping and articulation work. The EHR...... implementation stressed their importance to the departments' work arrangements, coupled their work more tightly to that of other staff, and led to task drift among professions. information is complete, up to date, and correctly coded. Medical secretaries While medical secretaries have been relatively invisible...

  8. Medical records and issues in negligence

    Directory of Open Access Journals (Sweden)

    Joseph Thomas

    2009-01-01

    conducted with the concurrence of the patient. A properly written operative note can protect a surgeon in case of alleged negligence due to operative complications. It is important that the prescription for drugs should be legible with the name of the patient, date, and the signature of the doctor. An undated prescription can land a doctor in trouble if the patient misuses it. There are also many records that are indirectly related to patient management such as accounts records, service records of the staff, and administrative records, which are also useful as evidences for litigation purposes. Medical recording needs the concerted effort of a number of people involved in patient care. The doctor is the prime person who has to oversee this process and is primarily responsible for history, physical examination, treatment plans, operative records, consent forms, medications used, referral papers, discharge records, and medical certificates. There should be proper recording of nursing care, laboratory data, reports of diagnostic evaluations, pharmacy records, and billing processes. This means that the paramedical and nursing staff also should be trained in proper maintenance of patient records. The medical scene in India extends from smaller clinics to large hospitals. Medical record keeping is a specialized area in bigger teaching and corporate hospitals with separate medical records officers handling these issues. However, it is yet to develop into a proper process in the large number of smaller clinics and hospitals that cater to a large section of the people in India.

  9. Medical records and issues in negligence.

    Science.gov (United States)

    Thomas, Joseph

    2009-07-01

    the patient. A properly written operative note can protect a surgeon in case of alleged negligence due to operative complications. It is important that the prescription for drugs should be legible with the name of the patient, date, and the signature of the doctor. An undated prescription can land a doctor in trouble if the patient misuses it. There are also many records that are indirectly related to patient management such as accounts records, service records of the staff, and administrative records, which are also useful as evidences for litigation purposes. Medical recording needs the concerted effort of a number of people involved in patient care. The doctor is the prime person who has to oversee this process and is primarily responsible for history, physical examination, treatment plans, operative records, consent forms, medications used, referral papers, discharge records, and medical certificates. There should be proper recording of nursing care, laboratory data, reports of diagnostic evaluations, pharmacy records, and billing processes. This means that the paramedical and nursing staff also should be trained in proper maintenance of patient records. The medical scene in India extends from smaller clinics to large hospitals. Medical record keeping is a specialized area in bigger teaching and corporate hospitals with separate medical records officers handling these issues. However, it is yet to develop into a proper process in the large number of smaller clinics and hospitals that cater to a large section of the people in India.

  10. Medical Secretaries’ Care of Records

    DEFF Research Database (Denmark)

    Bossen, Claus; Jensen, Lotte Groth; Witt, Flemming

    2012-01-01

    We describe the cooperative work of medical secretaries at two hospital departments, during the implementation of an electronic health record system. Medical secretaries' core task is to take care of patient records by ensuring that also do information gatekeeping and articulation work. The EHR...... to health informatics and CSCW, this case study identifies their importance, and suggests that they and other non-clinical groups should be considered, when developing health care IT. We propose the term 'boundary-object trimming', to conceptualize their contributions to hospitals' cooperative work...

  11. 42 CFR 460.210 - Medical records.

    Science.gov (United States)

    2010-10-01

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

  12. Medical Archive Recording System (MARS

    Directory of Open Access Journals (Sweden)

    Mohammad Reza Tajvidi

    2007-08-01

    Full Text Available In this talk, one of the most efficient, and reliable integrated tools for CD/DVD production workflow, called Medical Archive Recording System (MARS by ETIAM Company, France, which is a leader in multimedia connectivity for healthcare in Europe, is going to be introduced. "nThis tool is used to record all patient studies, route the studies to printers and PACS automatically, print key images and associated reports and log all study production for automated post processing/archiving. Its benefits vary from multi-departmental system to highly customizability, IHE compliancy, high productivity, inclusion of workflow manager and web interface."nAn automated user-friendly DICOM viewer is in-cluded in this tool, which is used to display reports and key image. It also allows comparing several stu-dies on several discs."nThe viewer supports all DICOM objects including compressed images such as JPEG, JPEG 2000, RLE etc. and video added-value non-image DICOM ob-jects."nThe ETIAM MARS is offered in two versions: MARS 15d for medium productions and MARS 20d for medium to large productions. Some of the new features that are added are supports for Windows Vista, support of new DICOM objects (enhanced CT, MR, XA, Encapsulated PDF ... IHE PDI update, creation of object keys for key images; importing non-standard reports form files and many other features."nThe tool enables users to create, verify and index CDs and DVDs by simply sending studies from any DICOM node.

  13. Medical Practitioners Act 2007: the increased medical record burden.

    LENUS (Irish Health Repository)

    Byrne, D

    2010-03-01

    New medical record keeping obligations are implemented by the Medical Practitioners Act (2007), effective July 2009. This audit, comprising review of 347 medical entries in 257 charts on one day, investigated compliance with the Act together with the general standard of medical record keeping. The Medical Council requirement was absent all but 3 (0.9%) of entries; there was no unique identifier or signature in 28 (8%) and 135 (39%) of entries respectively. The case for change is discussed.

  14. Some comments about the medical record

    Directory of Open Access Journals (Sweden)

    Alfredo Darío Espinosa Brito

    2010-12-01

    Full Text Available Some issues are commented about the medical records at present. There are included aspects as: history, importance, how to teach its performance, different functions, types of medical charts, and individual and institutional responsabilities with this document.

  15. Medical Records and Health Information Technicians

    Science.gov (United States)

    ... Projected Employment, 2024 Change, 2014-24 Employment by Industry Percent Numeric SOURCE: U.S. Bureau of Labor Statistics, Employment Projections program Medical records and health information ...

  16. Medical records in equine veterinary practice.

    Science.gov (United States)

    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.

  17. Medical Services: Nursing Records and Reports

    Science.gov (United States)

    2007-11-02

    11) Item 11. Self–explanatory. (12) Item 12. Record if electrosurgical unit (ESU) was used by “X” in the YES or NO block. Enter medical maintenance...Guard cc cubic centimeter CNS clinical nurse specialist ESU electrosurgical unit expir expiration HR health record (records filed in DA Form 3444

  18. Controlled dissemination of Electronic Medical Records

    NARCIS (Netherlands)

    van 't Noordende, G.

    2011-01-01

    Building upon a security analysis of the Dutch electronic patient record system, this paper describes an approach to construct a fully decentralized patient record system, using controlled disclosure of references to medical records. This paper identifies several paths that can be used to disclose

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

    Science.gov (United States)

    Voskuil, P H

    1992-09-05

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

  20. Electronic medical record: Time to migrate?

    Science.gov (United States)

    Rustagi, Neeti; Singh, Ritesh

    2012-10-01

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

  1. Electronic medical record: Time to migrate?

    Directory of Open Access Journals (Sweden)

    Neeti Rustagi

    2012-01-01

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

  2. Information integrity and privacy for computerized medical patient records

    Energy Technology Data Exchange (ETDEWEB)

    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.

  3. Medical records and issues in negligence

    OpenAIRE

    Thomas, Joseph

    2009-01-01

    It is very important for the treating doctor to properly document the management of a patient under his care. Medical record keeping has evolved into a science of itself. This will be the only way for the doctor to prove that the treatment was carried out properly. Moreover, it will also be of immense help in the scientific evaluation and review of patient management issues. Medical records form an important part of the management of a patient. It is important for the doctors and medical esta...

  4. Privacy, confidentiality, and electronic medical records.

    Science.gov (United States)

    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

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

    Science.gov (United States)

    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

  6. Electronic Medical Record Tobacco Use Vital Sign

    Directory of Open Access Journals (Sweden)

    Norris John W

    2004-06-01

    Full Text Available Abstract Objective Determination of the prevalence of tobacco use and impact of tobacco prevention/treatment efforts in an electronic medical record enabled practice utilizing a defined tobacco vital sign variable. Design and Measurements Retrospective cohort study utilizing patient data recorded in an electronic medical record database between July 15, 2001, and May 31, 2003. Patient-reported tobacco use status was obtained for each of 6,771 patients during the pre-provider period of their 24,824 visits during the study period with the recorder blinded to past tobacco use status entries. Results An overall current tobacco use prevalence of 27.1% was found during the study period. Tobacco use status was recorded in 96% of visits. Comparison of initial to final visit tobacco use status demonstrates a consistency rate of 75.0% declaring no change in tobacco status in the 4,522 patients with two or more visits. An 8.6% net tobacco use decline was seen for the practice (p value Conclusion Self reported tobacco use status as a vital sign embedded within the workflow of an electronic medical record enabled practice was a quantitative tool for determination of tobacco use prevalence and a measuring stick of risk prevention/intervention impact.

  7. CRFs based de-identification of medical records

    Science.gov (United States)

    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

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

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

    2007-01-01

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

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

    Science.gov (United States)

    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.

  11. Anonymization of Electronic Medical Records to Support Clinical Analysis

    CERN Document Server

    Gkoulalas-Divanis, Aris

    2013-01-01

    Anonymization of Electronic Medical Records to Support Clinical Analysis closely examines the privacy threats that may arise from medical data sharing, and surveys the state-of-the-art methods developed to safeguard data against these threats. To motivate the need for computational methods, the book first explores the main challenges facing the privacy-protection of medical data using the existing policies, practices and regulations. Then, it takes an in-depth look at the popular computational privacy-preserving methods that have been developed for demographic, clinical and genomic data sharing, and closely analyzes the privacy principles behind these methods, as well as the optimization and algorithmic strategies that they employ. Finally, through a series of in-depth case studies that highlight data from the US Census as well as the Vanderbilt University Medical Center, the book outlines a new, innovative class of privacy-preserving methods designed to ensure the integrity of transferred medical data for su...

  12. Adopting electronic medical records: are they just electronic paper records?

    Science.gov (United States)

    Price, Morgan; Singer, Alex; Kim, Julie

    2013-07-01

    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. Mixed-methods study. Manitoba. Health care providers and staff in 5 primary care offices. 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. 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. 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.

  13. Recent perspectives of electronic medical record systems.

    Science.gov (United States)

    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.

  14. Mining free-text medical records.

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  17. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Science.gov (United States)

    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...

  18. Electronic medical records and the gastroenterologist.

    Science.gov (United States)

    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.

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

    Directory of Open Access Journals (Sweden)

    Dan Belletti

    2010-04-01

    Full Text Available Dan Belletti1, Christopher Zacker1, C Daniel Mullins21Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA; 2University of Maryland School of Pharmacy, Baltimore, MD, USAAbstract: Health information technology (HIT is engineered to promote improved quality and efficiency of care, and reduce medical errors. Healthcare organizations have made significant investments in HIT tools and the electronic medical record (EMR is a major technological advance. The Department of Veterans Affairs was one of the first large healthcare systems to fully implement EMR. The Veterans Health Information System and Technology Architecture (VistA began by providing an interface to review and update a patient’s medical record with its computerized patient record system. However, since the implementation of the VistA system there has not been an overall substantial adoption of EMR in the ambulatory or inpatient setting. In fact, only 23.9% of physicians were using EMRs in their office-based practices in 2005. A sample from the American Medical Association revealed that EMRs were available in an office setting to 17% of physicians in late 2007 and early 2008. Of these, 17% of physicians with EMR, only 4% were considered to be fully functional EMR systems. With the exception of some large aggregate EMR databases the slow adoption of EMR has limited its use in outcomes research. This paper reviews the literature and presents the current status of and forces influencing the adoption of EMR in the office-based practice, and identifies the benefits, limitations, and overall value of EMR in the conduct of outcomes research in the US.Keywords: electronic medical records, health information technology, medical errors

  20. Recorded interviews with human and medical geneticists.

    Science.gov (United States)

    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.

  1. Electronic medical record and glaucoma medications: connecting the medication reconciliation with adherence

    Directory of Open Access Journals (Sweden)

    Bacon TS

    2016-01-01

    Full Text Available Thomas S Bacon, Kenneth C Fan, Manishi A Desai Department of Ophthalmology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA Purpose: To evaluate consistency in documentation of glaucoma medications in the electronic medical record and identify which regimen patients adhere to when inconsistencies exist. Factors contributing to medication nonadherence are also explored.Methods: Retrospective chart review of medication adherence encompassing 200 patients from three glaucoma physicians at a tertiary referral center over a 1-month period. Adherence was determined by the consistency between a patients stated medication regimen and either the active medication list in the electronic medical record, or the physicians planned medication regimen in the preceding clinic visit. Patient charts were also reviewed for patient sex, age, primary language, race, and total number of medications.Results: A total of 160 charts showed consistency in documentation between the physician note and electronic medication reconciliation. Of those patients, 83.1% reported adherence with their glaucoma medication schedule. When there was a discrepancy in documentation (40 charts, 72.5% patients followed the physician-stated regimen vs 20% who followed neither vs 7.5% who followed the medical record (P<0.01. No difference in adherence was observed based on sex (P=0.912 or total number of medications taken (P=0.242. ­Language, both English- (P=0.075 and Haitian (P=0.10 -speaking populations, as well as race, ­Caucasian (P=0.31, African-American (P=0.54, and Hispanic (P=0.58, had no impact on medication adherence. Patients over 80 years of age were more nonadherent as compared to other decades (P=0.04.Conclusion: Inconsistent documentation between the electronic medical record physician note and medication regimen may contribute to patient medication nonadherence. Patients over 80 years of age were associated with higher rates of nonadherence

  2. Free medical care and consumer protection.

    Science.gov (United States)

    Agrawal, Aniket Deepak; Banerjee, Arunabha

    2011-01-01

    This paper will examine the question of whether patients, who receive free medical care, whether from private charitable or governmental hospitals, can claim rights as 'consumers' under the Consumer Protection Act, 1986. The issue will be discussed from a constitutional perspective as well as that of the law of torts.

  3. Medical Records and Correspondence Demand Respect

    Directory of Open Access Journals (Sweden)

    M Benamer

    2007-01-01

    Full Text Available To The Editor: I was amazed recently to see a patient from Libya who came to the UK for treatment based on the advice of his Libyan physicians. The patient carried with him no referral letter whatsoever. Not one physician familiar with his case bothered to write a few lines for the poor patient, although each of those doctors saw the patient at least twice and prescribed one or more treatment. The patient carried with him different medications that had been prescribed, and a few empty containers of other medicines he had used. I mention the above short tale to bring to light what I feel is a major ethical problem with the way medicine is practiced in Libya [1]. The keeping of good medical records together with clear and concise correspondence between physicians is imperative for several reasons. Not only does it avoid duplication of services and unnecessary costs, it decreases the time invested by both the patient and physician, and it fosters a collegial relationship among healthcare providers. Many times, referring physicians may not know each other. It provides a channel for them to learn from each other as well as a method for them to form professional relationships. It occurred to me that colleagues in Libya may be shy of writing referral letters or may even be phobic about disclosing their practice habits. Patient information can best be written as referral letters which summaries the patient presentation, testing, response to treatment, possible consultation, and reason for referral. The referral may be because the physician(s initially treating the patient simply have tried all treatments known to them, or they may need to refer if they lack certain diagnostic equipment necessary to continue the care. To refer the patient to colleagues simply says “we think more can be done for this patient but we may not be able to do it here; please evaluate.” It shows respect for the patient and for the colleague. No physician knows everything

  4. Special radiation protection aspects of medical accelerators

    CERN Document Server

    Silari, Marco

    2001-01-01

    Radiation protection aspects relevant to medical accelerators are discussed. An overview is first given of general safety requirements. Next. shielding and labyrinth design are discussed in some detail for the various types of accelerators, devoting more attention to hadron machines as they are far less conventional than electron linear accelerators. Some specific aspects related to patient protection are also addressed. Finally, induced radioactivity in accelerator components and shielding walls is briefly discussed. Three classes of machines are considered: (1) medical electron linacs for 'conventional' radiation therapy. (2) low energy cyclotrons for production of radionuclides mainly for medical diagnostics and (3) medium energy cyclotrons and synchrotrons for advanced radiation therapy with protons or light ion beams (hadron therapy). (51 refs).

  5. The use of protective gloves by medical personnel

    Directory of Open Access Journals (Sweden)

    Anna Garus-Pakowska

    2013-06-01

    Full Text Available Introduction: To minimize the risk of cross-infection between the patient and the medical staff, it is necessary to use individual protective measures such as gloves. According to the recommendations of the Centers for Disease Control and Prevention (CDC and the World Health Organization (WHO, protective gloves should always be used upon contact with blood, mucosa, injured skin or other potentially infectious material. Materials and Methods: The aim of the study was to evaluate, through quasi-observation, the use of protective gloves by medical staff according to the guidelines issued by the CDC and WHO. The results were subject to statistical analysis (p < 0.05. Results: During 1544 hours of observations, 3498 situations were recorded in which wearing protective gloves is demanded from the medical staff. The overall percentage of the observance of using gloves was 50%. The use of gloves depended significantly on the type of ward, profession, performed activity, number of situations that require wearing gloves during the observation unit and the real workload. During the entire study, as many as 718 contacts with patients were observed in which the same gloves were used several times. Conclusion: Wearing disposable protective gloves by the medical staff is insufficient.

  6. Collaborative Affordances of Hybrid Patient Record Technologies in Medical Work

    DEFF Research Database (Denmark)

    Houben, Steven; Frost, Mads; Bardram, Jakob E

    2015-01-01

    The medical record is a central artifact used to organize, communicate and coordinate information related to patient care. Despite recent deployments of electronic health records (EHR), paper medical records are still widely used because of the affordances of paper. Although a number of approaches...... to digitally augment a paper medical record. We report on two studies: a field study in which we describe the benefits and challenges of using a combination of electronic and paper-based medical records in a large university hospital and a deployment study in which we analyze how 8 clinicians used the Hy...

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

    Science.gov (United States)

    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.

  8. The potential of electronic medical records for health service management.

    NARCIS (Netherlands)

    Zee, J. van der; Fleming, D.M.

    2006-01-01

    The medical record held in primary care provides the most comprehensive summary of all medical events. Diagnostic, laboratory, and prescribing data are all linked in individual patient records. Networks of GPs in some European countries are routinely recording data electronically in a way which allo

  9. The potential of electronic medical records for health service management.

    NARCIS (Netherlands)

    Zee, J. van der; Fleming, D.M.

    2006-01-01

    The medical record held in primary care provides the most comprehensive summary of all medical events. Diagnostic, laboratory, and prescribing data are all linked in individual patient records. Networks of GPs in some European countries are routinely recording data electronically in a way which

  10. Reflecting on the ethical administration of computerized medical records

    Science.gov (United States)

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

    Science.gov (United States)

    2010-01-01

    ... 5 Administrative Personnel 1 2010-01-01 2010-01-01 false Establishment and protection of Employee Medical Folder. 293.505 Section 293.505 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT CIVIL SERVICE REGULATIONS PERSONNEL RECORDS Employee Medical File System Records § 293.505 Establishment...

  12. Evaluating Documentation of Dietetic Care in Swedish Medical Records

    OpenAIRE

    Lövestam, Elin; Orrevall, Ylva; Koochek, Afsaneh; Karlström, Brita; Andersson, Agneta

    2013-01-01

    An adequate documentation in medical records is essential for patient safety and high quality care. The aim of this study was to evaluate documentation by dietitians in Swedish medical records. A retrospective audit of 147 dietetic notes in electronic medical records was performed. The audit focused at documentation of essential parts of the dietetic care, as well as other quality aspects such as lingual clarity and structure of the documentation. The nutrition intervention showed to be the m...

  13. Privacy Impact Assessment for the Wellness Program Medical Records

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

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

    OpenAIRE

    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 chara...

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

    Directory of Open Access Journals (Sweden)

    Long William J

    2008-07-01

    Full Text Available Abstract Background 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. Methods 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. Results 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

  17. Technology Acceptance of Electronic Medical Records by Nurses

    Science.gov (United States)

    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. Collaborative Affordances of Hybrid Patient Record Technologies in Medical Work

    DEFF Research Database (Denmark)

    Houben, Steven; Frost, Mads; Bardram, Jakob E

    2015-01-01

    The medical record is a central artifact used to organize, communicate and coordinate information related to patient care. Despite recent deployments of electronic health records (EHR), paper medical records are still widely used because of the affordances of paper. Although a number of approache......PR in a medical simulation. Based on these empirical studies, this paper introduces and discusses the concept of collaborative affordances, which describes a set of properties of the medical record that foster collaborative collocated work.......The medical record is a central artifact used to organize, communicate and coordinate information related to patient care. Despite recent deployments of electronic health records (EHR), paper medical records are still widely used because of the affordances of paper. Although a number of approaches...... explored the integration of paper and digital technology, there are still a wide range of open issues in the design of technologies that integrate digital and paper-based medical records. This paper studies the use of one such novel technology, called the Hybrid Patient Record (HyPR), that is designed...

  19. Collaborative Affordances of Hybrid Patient Record Technologies in Medical Work

    DEFF Research Database (Denmark)

    Houben, Steven; Frost, Mads; Bardram, Jakob E

    2015-01-01

    to digitally augment a paper medical record. We report on two studies: a field study in which we describe the benefits and challenges of using a combination of electronic and paper-based medical records in a large university hospital and a deployment study in which we analyze how 8 clinicians used the Hy......PR in a medical simulation. Based on these empirical studies, this paper introduces and discusses the concept of collaborative affordances, which describes a set of properties of the medical record that foster collaborative collocated work....... explored the integration of paper and digital technology, there are still a wide range of open issues in the design of technologies that integrate digital and paper-based medical records. This paper studies the use of one such novel technology, called the Hybrid Patient Record (HyPR), that is designed...

  20. Management of medical records: facts and figures for surgeons.

    Science.gov (United States)

    Bali, Amit; Bali, Deepika; Iyer, Nageshwar; Iyer, Meenakshi

    2011-09-01

    Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication. If written correctly, notes will support the doctor about the correctness of treatment. Inspite of knowing the importance of proper record keeping in India, it is still in the initial stages. Medical records are the one of the most important aspect on which practically almost every medico-legal battle is won or lost. This article discusses the various aspect of record maintenance.

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

    Science.gov (United States)

    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

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

    Science.gov (United States)

    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.

  3. Medical record review for clinical pertinence.

    Science.gov (United States)

    Lewis, K S

    1991-08-01

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

  4. Implications of WWW technologies for exchanging medical records

    Directory of Open Access Journals (Sweden)

    Maurice Dixon

    1999-09-01

    Full Text Available This article addresses some of the implications for medical record exchange of very recent developments in technology and tools that support the World Wide Web. It argues that XML (Extensible Mark-up Language is a very good enabling technology for medical record exchange. XML provides a much cheaper way of executing the exchange of medical information that circumvents the need for proprietary software. Use of XML can also simplify solutions to the problems associated with coping with the evolution of medical systems in time. However XML on its own does not resolve all the semantic heterogeneities.

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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 documentation for advanced directives (P = 0.145).

  7. Electronic medical records system user acceptance

    CSIR Research Space (South Africa)

    Erasmus, L

    2015-06-01

    Full Text Available   and  tracing  the  ‘sociability’  of  especially  medical  technologies  could thus help to elucidate why some people do or do not  like to use these technologies  (Pols &  Moser, 2009:161) and... slow to adopt EMR technology due to the believe that the new technology will have a negative  effect on  their medical practice with aspects of  cost,  support and ability  to use  the new  systems  being  cited  as  reasons  (Riesenmy,  2010:164).  Riesenmy  (2010:164)  continued  by  stating  that  physicians would be  less  likely  to...

  8. Confidentiality Protection of Digital Health Records in Cloud Computing.

    Science.gov (United States)

    Chen, Shyh-Wei; Chiang, Dai Lun; Liu, Chia-Hui; Chen, Tzer-Shyong; Lai, Feipei; Wang, Huihui; Wei, Wei

    2016-05-01

    Electronic medical records containing confidential information were uploaded to the cloud. The cloud allows medical crews to access and manage the data and integration of medical records easily. This data system provides relevant information to medical personnel and facilitates and improve electronic medical record management and data transmission. A structure of cloud-based and patient-centered personal health record (PHR) is proposed in this study. This technique helps patients to manage their health information, such as appointment date with doctor, health reports, and a completed understanding of their own health conditions. It will create patients a positive attitudes to maintain the health. The patients make decision on their own for those whom has access to their records over a specific span of time specified by the patients. Storing data in the cloud environment can reduce costs and enhance the share of information, but the potential threat of information security should be taken into consideration. This study is proposing the cloud-based secure transmission mechanism is suitable for multiple users (like nurse aides, patients, and family members).

  9. Towards Semantic Search and Inference in Electronic Medical Records

    Directory of Open Access Journals (Sweden)

    Bevan Koopman

    2012-09-01

    Full Text Available Background This paper presents a novel approach to searching electronic medical records that is based on concept matching rather than keyword matching. Aims The concept-based approach is intended to overcome specific challenges we identified in searching medical records. Method Queries and documents were transformed from their term-based originals into medical concepts as defined by the SNOMED-CT ontology. Results Evaluation on a real-world collection of medical records showed our concept-based approach outperformed a keyword baseline by 25% in Mean Average Precision. Conclusion The concept-based approach provides a framework for further development of inference based search systems for dealing with medical data.

  10. A Medical Record of Systemic Lupus Erythematosus

    Institute of Scientific and Technical Information of China (English)

    2001-01-01

    @@Case History Patient Chen, female, 68 years, case number: 9800297; date of hospitalization: May 11, 1998. Chief complaints: Fever accompanied with cough and lassitude for 3 months and skin rash for 7 days. History of present illness: In early Feb. 1998, the patient got fever accompanied with cough, chest distress, and expectoration of sticky sputum. She had been diagnosed at a hospital and later at a clinic as chronic bronchitis and pneumonia, and treated for more than 50 days with antibiotics and medication of some drugs for cough and sputum, but with no complete remission of the symptoms. One week previously, she developed general skin rash mainly in the face, accompanied with itching, high body temperature of 38~39℃, aggravated cough and chest distress, lassitude, poor appetite, slight thirst, absence of bowel movement for 3 days, and yellow brownish urine.

  11. Evaluation of Randomly Selected Completed Medical Records Sheets in Teaching Hospitals of Jahrom University of Medical Sciences, 2009

    Directory of Open Access Journals (Sweden)

    Mohammad Parsa Mahjob

    2011-06-01

    Full Text Available Background and objective: Medical record documentation, often use to protect the patients legal rights, also providing information for medical researchers, general studies, education of health care staff and qualitative surveys is used. There is a need to control the amount of data entered in the medical record sheets of patients, considering the completion of these sheets is often carried out after completion of service delivery to the patients. Therefore, in this study the prevalence of completeness of medical history, operation reports, and physician order sheets by different documentaries in Jahrom teaching hospitals during year 2009 was analyzed. Methods and Materials: In this descriptive / retrospective study, the 400 medical record sheets of the patients from two teaching hospitals affiliated to Jahrom medical university was randomly selected. The tool of data collection was a checklist based on the content of medical history sheet, operation report and physician order sheets. The data were analyzed by SPSS (Version10 software and Microsoft Office Excel 2003. Results: Average of personal (Demography data entered in medical history, physician order and operation report sheets which is done by department's secretaries were 32.9, 35.8 and 40.18 percent. Average of clinical data entered by physician in medical history sheet is 38 percent. Surgical data entered by the surgeon in operation report sheet was 94.77 percent. Average of data entered by operation room's nurse in operation report sheet was 36.78 percent; Average of physician order data in physician order sheet entered by physician was 99.3 percent. Conclusion: According to this study, the rate of completed record papers reviewed by documentary in Jahrom teaching hospitals were not desirable and in some cases were very weak and incomplete. This deficiency was due to different reason such as medical record documentaries negligence, lack of adequate education for documentaries, High work

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  14. Practical fulltext search in medical records

    Directory of Open Access Journals (Sweden)

    Vít Volšička

    2015-09-01

    Full Text Available Performing a search through previously existing documents, including medical reports, is an integral part of acquiring new information and educational processes. Unfortunately, finding relevant information is not always easy, since many documents are saved in free text formats, thereby making it difficult to search through them. A full-text search is a viable solution for searching through documents. The full-text search makes it possible to efficiently search through large numbers of documents and to find those that contain specific search phrases in a short time. All leading database systems currently offer full-text search, but some do not support the complex morphology of the Czech language. Apache Solr provides full support options and some full-text libraries. This programme provides the good support of the Czech language in the basic installation, and a wide range of settings and options for its deployment over any platform. The library had been satisfactorily tested using real data from the hospitals. Solr provided useful, fast, and accurate searches. However, there is still a need to make adjustments in order to receive effective search results, particularly by correcting typographical errors made not only in the text, but also when entering words in the search box and creating a list of frequently used abbreviations and synonyms for more accurate results.

  15. System of Web-Based Electronic Medical Record

    Directory of Open Access Journals (Sweden)

    Maurício A. Machado

    2007-12-01

    Full Text Available Nowadays, the information systems are considered a tool to make-decision support in several areas. One of the applications of this system could be in the development of a web-based Electronic Medical Record. The attention to standards, naming, accurate measuring and the system security in the sense of information privacy are fundamental elements in the development of a web-based electronic medical record. Therefore, based on the solidarity and maturity of web applications, this work presents a solution that could supply the construction of electronic medical records by the internet. Recently, in the Brazilian market there have been few successful initiatives. Taking this into account, this work proposes the use of proven software development methodologies. How a study case was used the tengiology and vascular surgery. Currently the medical consultation processes of the angiology and vascular surgery specialties are operated manually. The final product provides automatization of these procedures.

  16. Electronic Health Record in Italy and Personal Data Protection.

    Science.gov (United States)

    Bologna, Silvio; Bellavista, Alessandro; Corso, Pietro Paolo; Zangara, Gianluca

    2016-06-01

    The present article deals with the Italian Electronic Health Record (hereinafter EHR), recently introduced by Act 221/2012, with a specific focus on personal data protection. Privacy issues--e.g., informed consent, data processing, patients' rights and minors' will--are discussed within the framework of recent e-Health legislation, national Data Protection Code, the related Data Protection Authority pronouncements and EU law. The paper is aimed at discussing the problems arising from a complex, fragmentary and sometimes uncertain legal framework on e-Health.

  17. Protecting Student Records and Facilitating Education Research: A Workshop Summary

    Science.gov (United States)

    Hilton, Margaret

    2008-01-01

    Designed to protect the privacy of individual student test scores, grades, and other education records, the Family Educational Rights and Privacy Act (FERPA) of 1974 places limits the access of educational researches, and slows research not only in education but also in related fields, such as child welfare and health. Recent trends have converged…

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

    Science.gov (United States)

    Key, Diana; Ferneini, Elie M

    2015-09-01

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

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  1. The use of shared medication record as part of medication reconciliation at hospital admission is feasible

    DEFF Research Database (Denmark)

    Munck, Lars K; Hansen, Karina R; Mølbak, Anne Grethe

    2014-01-01

    INTRODUCTION: Medication reconciliation improves congruence in cross sectional patient courses. Our regional electronic medical record (EMR) integrates the shared medication record (SMR) which provides full access to current medication and medication prescriptions for all citizens in Denmark. We...... studied whether our SMR integration could facilitate medication reconciliation. MATERIAL AND METHODS: Patients admitted to the emergency department for hospitalization were randomised to consultation using EMR with or without the integrated SMR access. Observed time used for medication reconciliation...... was the primary efficacy parameter. RESULTS: A total of 62 consecutive patient consultations were randomised including 39 with more than five prescriptions. EMR had data from previous consultations for 46 patients, 59 patients provided information on medication. In all, 18 junior physicians in early postgraduate...

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  4. 36 CFR 1236.14 - What must agencies do to protect records against technological obsolescence?

    Science.gov (United States)

    2010-07-01

    ... protect records against technological obsolescence? 1236.14 Section 1236.14 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS ADMINISTRATION RECORDS MANAGEMENT ELECTRONIC RECORDS MANAGEMENT Records Management and Preservation Considerations for Designing and Implementing Electronic...

  5. Examination of an Electronic Patient Record Display Method to Protect Patient Information Privacy.

    Science.gov (United States)

    Niimi, Yukari; Ota, Katsumasa

    2017-02-01

    Electronic patient records facilitate the provision of safe, high-quality medical care. However, because personnel can view almost all stored information, this study designed a display method using a mosaic blur (pixelation) to temporarily conceal information patients do not want shared. This study developed an electronic patient records display method for patient information that balanced the patient's desire for personal information protection against the need for information sharing among medical personnel. First, medical personnel were interviewed about the degree of information required for both individual duties and team-based care. Subsequently, they tested a mock display method that partially concealed information using a mosaic blur, and they were interviewed about the effectiveness of the display method that ensures patient privacy. Participants better understood patients' demand for confidentiality, suggesting increased awareness of patients' privacy protection. However, participants also indicated that temporary concealment of certain information was problematic. Other issues included the inconvenience of removing the mosaic blur to obtain required information and risk of insufficient information for medical care. Despite several issues with using a display method that temporarily conceals information according to patient privacy needs, medical personnel could accept this display method if information essential to medical safety remains accessible.

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  8. Continued medication use in dentistry: the importance of dental records

    OpenAIRE

    de Medeiros, Glaucia Helena Faraco; Brüning, Vanessa

    2017-01-01

    Aim: Appoint the main chronic diseases and the most frequent medications used by the patients by the graduation students of Dentistry between 2012 and 2014/A,through patients’dentistry records.Material and Methods: Two studies were performed: one retrospective in patients’ dentistry records, attended at the Clinical School of Dentistry and a cross-sectional study with the students enrolled between the 6th and 9th semester in 2014/B. After the record, the data were inserted on an Excel® spread...

  9. Consumer protection... the realities of medical audit.

    Science.gov (United States)

    McKay, R

    1979-08-10

    The concept of medical audit is an extension of consumer philosophy, writes Ron McKay, but if you are paying for someone else's treatment how do you ensure your money has been spent correctly? In the United States the answer was auditing treatment and medical competence. In the light of the Royal Commission's recommendation for a greater degree of urgency in implementing medical audit here he asks how much can be learned from the US?

  10. Robust lossless watermarking based on circular interpretation of bijective transformations for the protection of medical databases.

    Science.gov (United States)

    Franco Contreras, J; Coatrieux, G; Chazard, E; Cuppens, F; Cuppens-Boulahia, N; Roux, C

    2012-01-01

    In this paper, we adapt the image lossless watermarking modulation proposed by De Vleeschouwer et al., based on the circular interpretation of bijective modulations, to the protection of medical relational databases. Our scheme modulates the numerical attributes of the database. It is suited for either copyright protection, integrity control or traitor tracing, being robust to most common database attacks, such as the addition and removal of tuples and the modification of attributes' values. Conducted experiments on a medical database of inpatient hospital stay records illustrate the overall performance of our method and its suitability to the requirements of the medical domain.

  11. Performance analysis of a medical record exchanges model.

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  13. Skin protection creams in medical settings: successful or evil?

    OpenAIRE

    Charlier Corinne; Denooz Raphaël; Macarenko Elena; Xhauflaire-Uhoda Emmanuelle; Piérard Gérald E

    2008-01-01

    Abstract Background Chronic exposure to mild irritants including cleansing and antiseptic products used for hand hygiene generates insults to the skin. To avoid unpleasant reactions, skin protection creams are commonly employed, but some fail to afford protection against a variety of xenobiotics. In this study, two skin protection creams were assayed comparatively looking for a protective effect if any against a liquid soap and an alcohol-based gel designed for hand hygiene in medical setting...

  14. Skin protection creams in medical settings: successful or evil?

    OpenAIRE

    Charlier Corinne; Denooz Raphaël; Macarenko Elena; Xhauflaire-Uhoda Emmanuelle; Piérard Gérald E

    2008-01-01

    Abstract Background Chronic exposure to mild irritants including cleansing and antiseptic products used for hand hygiene generates insults to the skin. To avoid unpleasant reactions, skin protection creams are commonly employed, but some fail to afford protection against a variety of xenobiotics. In this study, two skin protection creams were assayed comparatively looking for a protective effect if any against a liquid soap and an alcohol-based gel designed for hand hygiene in medical setting...

  15. Digital patient records and the medical desktop: an integrated physician workstation for medical informatics training.

    OpenAIRE

    Litt, H. I.; Loonsk, J. W.

    1992-01-01

    The Institute of Medicine and others have advocated a shift from a paper-based to an electronic medical record and many authorities have advanced the concept of a physician workstation that can provide access to a wide variety of both clinically and reference oriented medical information. We have developed a working model of an integrated physician workstation based on a graphically oriented "Medical Desktop," for personal computers. This system gives the user access to much of the informatio...

  16. Proposed Electronic Medical Record with Emphasis on Hepatitis Diagnosis

    Directory of Open Access Journals (Sweden)

    Georgios Skapetis

    2013-01-01

    Full Text Available Introduction Medical domain is characterized, like many other domains, by an exponential evolution of the knowledge. There are a lot of tools which try to reduce the risk of error apparition in medical life. Medical decision becomes a very hard activity because the human experts, who have to make decisions, can hardly process the huge amounts of data. Diagnosis has a very important role here. It is the first step from a set of therapeutic actions, an error at this level can have dramatic consequences.The aim of this paper is to present a new electronic medical system for using it on patients with hepatitis virusinfection.Results: Hepatitis is a very complicated disease with numerous different types many of them can lead to serious diseases like cirrhosis and liver cancer. An early correct diagnosis and an adequate treatment could reduce the risks of liver cancer apparition or other severe diseases. The main goal of the system is to use artificial intelligence in order to offer predictions about patients infected with hepatitis virus and also to follow the healthcondition of the patient reevaluating at every time the initial diagnosis and suggesting tests and treatment. Our effort is to present a new electronic medical record that will “borrow” data from the standard health record of the patient and other resources where information is saved and will process it and give suggestions for the diagnosis and treatment of the patient and at the same time will use a simple operating environment, such as the internet, thus making it easy to use.Conclusions The medical record is a big step in improving health services in public hospitals. The proposed EMR with the use of artificial intelligence is the next logical step that will help in the diagnosis and early treatment of disease.

  17. Electronic Health Record A Systems Analysis of the Medications Domain

    CERN Document Server

    Scarlat, Alexander

    2012-01-01

    An accessible primer, Electronic Health Record: A Systems Analysis of the Medications Domain introduces the tools and methodology of Structured Systems Analysis as well as the nuances of the Medications domain. The first part of the book provides a top-down decomposition along two main paths: data in motion--workflows, processes, activities, and tasks in parallel to the analysis of data at rest--database structures, conceptual, logical models, and entities relationship diagrams. Structured systems analysis methodology and tools are applied to: electronic prescription, computerized physician or

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

    Science.gov (United States)

    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.

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

    Directory of Open Access Journals (Sweden)

    Dong Xu

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

  20. Using Organizational Development for Electronic Medical Record Transformation.

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  2. Automated electronic medical record sepsis detection in the emergency department

    OpenAIRE

    Su Q. Nguyen; Edwin Mwakalindile; Booth, James S.; Vicki Hogan; Jordan Morgan; Prickett, Charles T; Donnelly, John P; Wang, Henry E.

    2014-01-01

    Background. While often first treated in the emergency department (ED), identification of sepsis is difficult. Electronic medical record (EMR) clinical decision tools offer a novel strategy for identifying patients with sepsis. The objective of this study was to test the accuracy of an EMR-based, automated sepsis identification system. Methods. We tested an EMR-based sepsis identification tool at a major academic, urban ED with 64,000 annual visits. The EMR system collected vital sign and lab...

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

    Science.gov (United States)

    Xie, Zhong; Gregg, Peggy; Zhang, Jiajie

    2003-01-01

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

  4. Brief review: dangers of the electronic medical record

    Directory of Open Access Journals (Sweden)

    Robbins RA

    2015-04-01

    Full Text Available EMRs represent a potential boon to patient care and providers, but to date that potential has been unfulfilled. Data suggest that in some instances EMRs may even produce adverse outcomes. This result probably has occurred because lack of provider input and familiarity with EMRs resulting in the medical records becoming less a tool for patient care and more of a tool for documentation and reimbursement.

  5. Automated electronic medical record sepsis detection in the emergency department

    OpenAIRE

    Nguyen, Su Q.; Edwin Mwakalindile; Booth, James S.; Vicki Hogan; Jordan Morgan; Prickett, Charles T; Donnelly, John P.; Wang, Henry E.

    2014-01-01

    Background. While often first treated in the emergency department (ED), identification of sepsis is difficult. Electronic medical record (EMR) clinical decision tools offer a novel strategy for identifying patients with sepsis. The objective of this study was to test the accuracy of an EMR-based, automated sepsis identification system. Methods. We tested an EMR-based sepsis identification tool at a major academic, urban ED with 64,000 annual visits. The EMR system collected vital sign and lab...

  6. Automated electronic medical record sepsis detection in the Emergency Department

    OpenAIRE

    Nguyen, Su; Mwakalindile, Edwin; Booth, James S.; Hogan, Vicki; Morgan, Jordan; Prickett, Charles T; Donnelly, John P.; Wang, Henry E.

    2014-01-01

    Background: While often first treated in the Emergency Department (ED), identification of sepsis is difficult. Electronic medical record (EMR) clinical decision tools offer a novel strategy for identifying patients with sepsis. The objective of this study was to test the accuracy of an EMR-based, automated sepsis identification system. Methods : We tested an EMR-based sepsis identification tool at a major academic, urban ED with 64,000 annual visits. The EMR system collected vital sign and la...

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  9. Semantic models in medical record data-bases.

    Science.gov (United States)

    Cerutti, S

    1980-01-01

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

  10. [ELGA--the electronic health record in the light of data protection and data security].

    Science.gov (United States)

    Ströher, Alexander; Honekamp, Wilfried

    2011-07-01

    The introduction of an electronic health record (ELGA) is a subject discussed for a long time in Austria. Another big step toward ELGA is made at the end of 2010 on the pilot project e-medication in three model regions; other projects should follow. In addition, projects of the ELGA structure are sped up on the part of the ELGA GmbH to install the base of a functioning electronic health record. Unfortunately, many of these initiatives take place, so to speak, secretly, so that in the consciousness of the general public - and that includes not only patients but also physicians and other healthcare providers - always concerns about protection and security of such a storage of health data arouse. In this article the bases of the planned act are discussed taking into account the data protection and data security.

  11. [Protection of medical personnel in contemporary armed conflicts].

    Science.gov (United States)

    Goniewicz, Krzysztof; Goniewicz, Mariusz; Pawłowski, Witold

    2016-01-01

    International humanitarian law provides special protection devices and medical personnel during armed conflicts. In today's wars it became more frequent lack of respect for the protective emblems of the red cross and red crescent and the lack of respect for medical activities. The paper presents selected issues of humanitarian law with a particular emphasis on the rules concerning the protection of medical services and victims of armed conflicts. All countries that have ratified the Geneva Conventions and Additional Protocols, are required to comply in time of war the principles contained in them and their dissemination in peacetime. Education societies in the field of international humanitarian law can help to eliminate attacks on medical facilities and personnel and significantly improve the fate of the victims of armed conflict and mitigate the cruelty of war. Knowledge of humanitarian law does not prevent further wars, but it can cause all parties to any armed conflict will abide by its rules during such activities.

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

    Science.gov (United States)

    Grams, R R; Moyer, E H

    1997-02-01

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

  13. NATIONAL SYNCHROTRON LIGHT SOURCE MEDICAL PERSONNEL PROTECTION INTERLOCK

    Energy Technology Data Exchange (ETDEWEB)

    BUDA,S.; GMUR,N.F.; LARSON,R.; THOMLINSON,W.

    1998-11-03

    This report is founded on reports written in April 1987 by Robert Hettel for angiography operations at the Stanford Synchrotron Research Laboratory (SSRL) and a subsequent report covering angiography operations at the National Synchrotron Light Source (NSLS); BNL Informal Report 47681, June 1992. The latter report has now been rewritten in order to accurately reflect the design and installation of a new medical safety system at the NSLS X17B2 beamline Synchrotron Medical Research Facility (SMERF). Known originally as the Angiography Personnel Protection Interlock (APPI), this system has been modified to incorporate other medical imaging research programs on the same beamline and thus the name has been changed to the more generic Medical Personnel Protection Interlock (MPPI). This report will deal almost exclusively with the human imaging (angiography, bronchography, mammography) aspects of the safety system, but will briefly explain the modular aspects of the system allowing other medical experiments to be incorporated.

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

    Science.gov (United States)

    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

  15. Health protection at the Savannah River Site: A guide to records series of the Department of Energy and its contractors

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    1996-09-01

    As part of the Department of Energy`s (DOE) Epidemiologic Records Inventory Project, History Associates Incorporated (HAI) prepared this guide to the records series pertaining to health protection activities at the DOE`s Savannah River Site (SRS). Since its inception in the early 1950s, the SRS, formerly known as the Savannah River Plant (SRP), has demonstrated significant interest in safeguarding facilities, protecting employees` health, and monitoring the environment. The guide describes records that concern health protection program administration, radiological monitoring of the plant and the environment, calibration and maintenance of monitoring instruments, internal and external dosimetry practices, medical surveillance of employees, occupational safety and training measures, site visitation, and electronic information systems. The introduction to the guide describes the Epidemiologic Records Inventory Project and HAI`s role in the project. It provides brief histories of the DOE, SRS, and the SRS organizational units responsible for health protection activities. This introduction also summarizes HAI`s methodology in developing criteria and conducting its verification of the SRS inventory of active and inactive SRS Health Protection records. Furthermore, it furnishes information on the production of the guide, the content of the records series descriptions, the location of the records, and the procedures for accessing records repositories.

  16. [Implantable loop recorder of the Confirm family (St. Jude Medical)].

    Science.gov (United States)

    Pujdak, Krzysztof

    2016-12-01

    St. Jude Medical produces the implantable loop recorder (ILR) Confirm AF DM2102 which offers subcutaneous electrodes on both sides of the device, a specific sensing algorithm and extensive storage capacity for up to 147 episodes. The reliability of detection of atrial fibrillation (AF) has been evaluated in the DETECT-AF study. The device is MR-conditional and allows patients an interrogation at home. The data are transferred to the follow-up centre via telephone by the patient activator, although this process is currently rather complex and slow. Therefore, remote monitoring of the Confirm AF DM2102 is rarely an option for elderly patients. St. Jude medical announced the introduction of a new, substantially smaller ILR using more modern technology by the end of 2016.

  17. Selections of Proven Medical Records in Acupuncture: Part Ⅰ

    Institute of Scientific and Technical Information of China (English)

    YANG Jie-bin; XIAO Yuan-chun

    2004-01-01

    @@ Editor's Note: Pro. YANG Jie-bin specializes in acupuncture and herbology in treating diseases of internal medincine, gynecology, pediatrics and dermatology. He treats difficult and stubborn diseases through meridian differentiation of pathogenesis, treating pain syndrome by unblocking meridians and harmonizing qi and blood,treating acute and chronic stomach diseases from regulatingthe liver and spleen, treating liver and gallbladder diseases by discharging the liver and clearing the gallbladder, all with excellent effects. From this issue,we will publish his some proven medical records in acupuncture.

  18. Electronic medical records: a developing and developed country analysis

    CSIR Research Space (South Africa)

    Sikhondze, NC

    2016-05-01

    Full Text Available of EMR systems. A model called The Electronic Medical Records Adoption Model (EMRAM) is used to measure and quantify adoption levels of EMR systems. EMRAM is used by Canada, core hospitals in Europe, the Middle East, Asia and Australia (Health... Economic Forum’s World Competitiveness Reports (2008:15, 2009:17, 2010:19, 2011:17, 2012:17, 2013:17) Figure 0. Trends of the GCI Score of pillar 4 for South Africa In South Africa; the healthcare services are divided into public and private...

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

    Science.gov (United States)

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

    2012-01-01

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

  20. Radiation protection in medical imaging and radiation oncology

    CERN Document Server

    Stoeva, Magdalena S

    2016-01-01

    Radiation Protection in Medical Imaging and Radiation Oncology focuses on the professional, operational, and regulatory aspects of radiation protection. Advances in radiation medicine have resulted in new modalities and procedures, some of which have significant potential to cause serious harm. Examples include radiologic procedures that require very long fluoroscopy times, radiolabeled monoclonal antibodies, and intravascular brachytherapy. This book summarizes evidence supporting changes in consensus recommendations, regulations, and health physics practices associated with these recent advances in radiology, nuclear medicine, and radiation oncology. It supports intelligent and practical methods for protection of personnel, the public, and patients. The book is based on current recommendations by the International Commission on Radiological Protection and is complemented by detailed practical sections and professional discussions by the world’s leading medical and health physics professionals. It also ...

  1. Meeting the security requirements of electronic medical records in the ERA of high-speed computing.

    Science.gov (United States)

    Alanazi, H O; Zaidan, A A; Zaidan, B B; Kiah, M L Mat; Al-Bakri, S H

    2015-01-01

    This study has two objectives. First, it aims to develop a system with a highly secured approach to transmitting electronic medical records (EMRs), and second, it aims to identify entities that transmit private patient information without permission. The NTRU and the Advanced Encryption Standard (AES) cryptosystems are secured encryption methods. The AES is a tested technology that has already been utilized in several systems to secure sensitive data. The United States government has been using AES since June 2003 to protect sensitive and essential information. Meanwhile, NTRU protects sensitive data against attacks through the use of quantum computers, which can break the RSA cryptosystem and elliptic curve cryptography algorithms. A hybrid of AES and NTRU is developed in this work to improve EMR security. The proposed hybrid cryptography technique is implemented to secure the data transmission process of EMRs. The proposed security solution can provide protection for over 40 years and is resistant to quantum computers. Moreover, the technique provides the necessary evidence required by law to identify disclosure or misuse of patient records. The proposed solution can effectively secure EMR transmission and protect patient rights. It also identifies the source responsible for disclosing confidential patient records. The proposed hybrid technique for securing data managed by institutional websites must be improved in the future.

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

    Science.gov (United States)

    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.

  3. Medical records confidentiality and public health research: two values at stake? An italian survey focus on individual preferences.

    Science.gov (United States)

    Toccaceli, Virgilia; Fagnani, Corrado; Stazi, Maria Antonietta

    2015-02-20

    In a time when Europe is preparing to introduce new regulations on privacy protection, we conducted a survey among 1700 twins enrolled in the Italian Twin Register about the access and use of their medical records for public health research without explicit informed consent. A great majority of respondents would refuse or are doubtful about the access and use of hospital discharge records or clinical data without their explicit consent. Young and female individuals represent the modal profile of these careful people. As information retrieved from medical records is crucial for progressing knowledge, it is important to promote a better understanding of the value of public health research activities among the general population. Furthermore, public opinions are relevant to policy making, and concerns and preferences about privacy and confidentiality in research can contribute to the design of procedures to exploit medical records effectively and customize the protection of individuals' medical data. Significance for public healthInformation retrieved from medical records is critical for public health research and policy. In particular, large amounts of individual health data are needed in an epidemiological setting, where methodological constraints (e.g. follow-up update) and quality control procedures very often require data to be re-identifiable. Concern about European regulation affecting access to medical records seems to be widespread in the scientific community. Highlighting individuals' concerns and preferences about privacy and informed consent regarding the use of health data can support policy making for public health research. It can contribute to the design of procedures aiming to extract the greatest value from medical records and, more importantly, to create a system for the protection of personal data tailored to the needs of different people.

  4. Improving standards of radiation protection in medical practice

    Energy Technology Data Exchange (ETDEWEB)

    Ginjaume, M.; Ortega, X. [Institute of Energy Technology, Universitat Politecnica de Catalunya - UPC (Spain); Carinou, E. [Greek Atomic Energy Commission - GAEC (Greece); Vanhavere, F. [Belgian Nuclear Research Centre, SCK.CEN (Belgium); Clairand, I. [Institut de Radioprotection et de Surete Nucleaire - IRSN (France); Gualdrini, G. [Ente per le Nuove Tecnologie, l' Energia e l' Ambiente - ENEA (Italy); Sans-Merce, M. [University Hospital Center Vaudois - CHUV (Switzerland)

    2010-07-01

    The use of ionizing radiation has led to major improvements in the diagnosis and treatment of patients. However, new developments in medical technology and the increased complexity of medical radiation techniques can produce high doses to medical personnel. In particular, interventional radiology and cardiology and nuclear medicine have been identified as fields where medical staff can receive potentially high doses. Within this framework, the ORAMED project, a collaborative project funded by the EU FP7, proposes new methodologies to improve standards of protection for medical staff. The main studied topics presented in this paper include extremity and eye-lens protection in interventional radiology and cardiology, extremity dosimetry in nuclear medicine, especially in therapy and positron emission tomography, and the evaluation and the improvement of active personal dosemeters used in pulsed medical radiation fields. An extensive dose measurement campaign of doses received in extremities and eye-lenses in more than 60 hospitals from 9 European countries has been undertaken. The analysis of the results highlights the most critical procedures and the effectiveness of the protection measures. (authors)

  5. Electronic medical record in cardiology: a 10-year Italian experience

    Directory of Open Access Journals (Sweden)

    Clara Carpeggiani

    2015-08-01

    Full Text Available SummaryObjectives:the aim of this study was to report a ten years experience in the electronic medical record (EMR use. An estimated 80% of healthcare transactions are still paper-based.Methods:an EMR system was built at the end of 1998 in an Italian tertiary care center to achieve total integration among different human and instrumental sources, eliminating paper-based medical records. Physicians and nurses who used EMR system reported their opinions. In particular the hospital activity supported electronically, regarding 4,911 adult patients hospitalized in the 2004- 2008 period, was examined.Results:the final EMR product integrated multimedia document (text, images, signals. EMR presented for the most part advantages and was well adopted by the personnel. Appropriateness evaluation was also possible for some procedures. Some disadvantages were encountered, such as start-up costs, long time required to learn how to use the tool, little to no standardization between systems and the EMR technology.Conclusion:the EMR is a strategic goal for clinical system integration to allow a better health care quality. The advantages of the EMR overcome the disadvantages, yielding a positive return on investment to health care organization.

  6. 77 FR 55221 - Agency Information Collection Activities: Report of Medical Examination and Vaccination Record...

    Science.gov (United States)

    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...

  7. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Science.gov (United States)

    2010-07-01

    ... of minors. Air Force personnel may disclose the medical records of minors to their parents or legal... abuse treatment, abortion, and birth control. If you manage medical records, learn the local laws and...

  8. Consistency in performance evaluation reports and medical records.

    Science.gov (United States)

    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

  9. Admission medical records made at night time have the same quality as day and evening time records

    DEFF Research Database (Denmark)

    Amirian, Ilda; Mortensen, Jacob F; Rosenberg, Jacob

    2014-01-01

    INTRODUCTION: A thorough and accurate admission medical record is an important tool in ensuring patient safety during the hospital stay. Surgeons' performance might be affected during night shifts due to sleep deprivation. The aim of the study was to assess the quality of admission medical records...

  10. 36 CFR 1202.42 - How are requests for access to medical records handled?

    Science.gov (United States)

    2010-07-01

    ... to medical records handled? 1202.42 Section 1202.42 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS ADMINISTRATION GENERAL RULES REGULATIONS IMPLEMENTING THE PRIVACY ACT OF 1974 Individual Access to Records § 1202.42 How are requests for access to medical records handled? When...

  11. Forward secure digital signature for electronic medical records.

    Science.gov (United States)

    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.

  12. Implementing electronic medical record systems in developing countries

    Directory of Open Access Journals (Sweden)

    Hamish Fraser

    2005-06-01

    Full Text Available The developing world faces a series of health crises including HIV/AIDS and tuberculosis that threaten the lives of millions of people. Lack of infrastructure and trained, experienced staff are considered important barriers to scaling up treatment for these diseases. In this paper we explain why information systems are important in many healthcare projects in the developing world. We discuss pilot projects demonstrating that such systems are possible and can expand to manage hundreds of thousands of patients. We also pass on the most important practical lessons in design and implementation from our experience in doing this work. Finally, we discuss the importance of collaboration between projects in the development of electronic medical record systems rather than reinventing systems in isolation, and the use of open standards and open source software.

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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

  15. Skin protection creams in medical settings: successful or evil?

    Science.gov (United States)

    Xhauflaire-Uhoda, Emmanuelle; Macarenko, Elena; Denooz, Raphaël; Charlier, Corinne; Piérard, Gérald E

    2008-07-25

    Chronic exposure to mild irritants including cleansing and antiseptic products used for hand hygiene generates insults to the skin. To avoid unpleasant reactions, skin protection creams are commonly employed, but some fail to afford protection against a variety of xenobiotics. In this study, two skin protection creams were assayed comparatively looking for a protective effect if any against a liquid soap and an alcohol-based gel designed for hand hygiene in medical settings. Corneosurfametry and corneoxenometry are two in vitro bioessays which were selected for their good reproducibility, sensitivity and ease of use. A Kruskal-Wallis ANOVA test followed by the Dunn test was realized to compare series of data obtained. Significant differences in efficacy were obtained between the two assayed skin protection creams. One of the two tested creams showed a real protective effect against mild irritants, but the other tested cream presented an irritant potential in its application with mild irritants. The differences observed for the two tested skin protection creams were probably due to their galenic composition and their possible interactions with the offending products. As a result, the present in vitro bioassays showed contrasted effects of the creams corresponding to either a protective or an irritant effect on human stratum corneum.

  16. Skin protection creams in medical settings: successful or evil?

    Directory of Open Access Journals (Sweden)

    Charlier Corinne

    2008-07-01

    Full Text Available Abstract Background Chronic exposure to mild irritants including cleansing and antiseptic products used for hand hygiene generates insults to the skin. To avoid unpleasant reactions, skin protection creams are commonly employed, but some fail to afford protection against a variety of xenobiotics. In this study, two skin protection creams were assayed comparatively looking for a protective effect if any against a liquid soap and an alcohol-based gel designed for hand hygiene in medical settings. Methods Corneosurfametry and corneoxenometry are two in vitro bioessays which were selected for their good reproducibility, sensitivity and ease of use. A Kruskal-Wallis ANOVA test followed by the Dunn test was realized to compare series of data obtained. Results Significant differences in efficacy were obtained between the two assayed skin protection creams. One of the two tested creams showed a real protective effect against mild irritants, but the other tested cream presented an irritant potential in its application with mild irritants. Conclusion The differences observed for the two tested skin protection creams were probably due to their galenic composition and their possible interactions with the offending products. As a result, the present in vitro bioassays showed contrasted effects of the creams corresponding to either a protective or an irritant effect on human stratum corneum.

  17. Medical Record Keeping in the Summer Camp Setting.

    Science.gov (United States)

    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

  18. Factors Affecting Accuracy of Data Abstracted from Medical Records.

    Directory of Open Access Journals (Sweden)

    Meredith N Zozus

    Full Text Available 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.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.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.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 the demonstrated

  19. Philosophy in medical education: a means of protecting mental health.

    Science.gov (United States)

    Keller, Eric J

    2014-08-01

    This study sought to identify and examine less commonly discussed challenges to positive mental health faced by medical students, residents, and physicians with hopes of improving current efforts to protect the mental health of these groups. Additionally, this work aimed to suggest an innovative means of preventing poor mental health during medical education. Literature on medical student, resident, and physician mental health was carefully reviewed and a number of psychiatrists who treat physician-patients were interviewed. The culture of medicine, medical training, common physician psychology and identity, and conflicting professional expectations all seem to contribute to poor mental health among medical students, residents, and physicians. Many current efforts may be more successful by better addressing the negative effects of these characteristics of modern medicine. Programs aimed at promoting healthy mental lifestyles during medical education should continue to be developed and supported to mitigate the deleterious effects of the challenging environment of modern medicine. To improve these efforts, educators may consider incorporating philosophical discussions on meaning and fulfillment in life between medical students and faculty. Through medical school faculty members sharing and living out their own healthy outlooks on life, students may emulate these habits and the culture of medicine may become less challenging for positive mental health.

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

    Science.gov (United States)

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

    2014-01-01

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

  1. Radiation Protection in Medical Physics : Proceedings of the NATO Advanced Study Institute on Radiation Protection in Medical Physics Activities

    CERN Document Server

    Lemoigne, Yves

    2011-01-01

    This book introduces the fundamental aspects of Radiation Protection in Medical Physics and covers three main themes: General Radiation Protection Principles; Radiobiology Principles; Radiation Protection in Hospital Medical Physics. Each of these topics is developed by analysing the underlying physics principles and their implementation, quality and safety aspects, clinical performance and recent advances in the field. Some issues specific to the individual techniques are also treated, e.g. calculation of patient dose as well as that of workers in hospital, optimisation of equipment used, shielding design of radiation facilities, radiation in oncology such as use of brachytherapy in gynecology or interventional procedures. All topics are presented with didactical language and style, making this book an appropriate reference for students and professionals seeking a comprehensive introduction to the field as well as a reliable overview of the most recent developments.

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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

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

    Science.gov (United States)

    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

  5. Protecting health from climate change: Preparedness of medical interns

    Directory of Open Access Journals (Sweden)

    Majra Jai

    2009-01-01

    Full Text Available Context : Climate change is a significant and emerging threat to public health and to meet the challenge, health systems require qualified staff. Aims : To study the preparedness of medical interns to meet the challenge of protecting health from climate change. Settings and Design: Medical colleges in a coastal town. Cross-sectional study. Materials and Methods: A proportionate number of medical interns from five medical colleges were included in the study. Level of awareness was used as a criterion to judge the preparedness. A self-administered, pretested, open-ended questionnaire was used. Responses were evaluated and graded. Statistical Analysis Used: Proportions, percentage, Chi-test. Results : About 90% of the medical interns were aware of the climate change and human activities that were playing a major role. Ninety-four percent were aware of the direct health impacts due to higher temperature and depletion in ozone concentration, and about 78% of the respondents were aware about the change in frequency / distribution of vector-borne diseases, water borne / related diseases, malnutrition, and health impact of population displacement. Knowledge regarding health protection was limited to mitigation of climate change and training / education. Options like adaptation, establishing / strengthening climate and disease surveillance systems, and health action in emergency were known to only nine (7%, eight (6%, and 17 (13%, respectively. Collegewise difference was statistically insignificant. Extra / co-curricular activities were the major source of knowledge. Conclusions : Majority of medical interns were aware of the causes and health impacts of climate change, but their knowledge regarding health protection measures was limited.

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

    Science.gov (United States)

    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.

  7. 医学生病历意识培养初探%Exploration of medical record consciousness with medical students

    Institute of Scientific and Technical Information of China (English)

    尤琳

    2011-01-01

    病历是医疗安全或医疗风险教育中不可忽视的重要内容.病历意识培养作为医疗安全教育的一部分,也是医学生综合素质教育的内容.目前,我国医学院校临床教学中除了病历书写的知识外,缺乏对医学生进行其他病历相关知识的基础教育.本文分析了医学生病历意识培养的背景和意义,并探讨了病历意识培养的途径.%The key role of the medical record in the discussion of medical security and medical risk should not be neglected and avoided.The training of medical record consciousness is an important part not only in medical security education but also in comprehensive quality education.At present, medical students are lack of medical record knowledge except of learning how to write medical records.The background and contents of medical record consciousness with medical students were analyzed, and gateway of the training of medical record consciousness was explored in this paper.

  8. [The revised system of hospitalization for medical care and protection].

    Science.gov (United States)

    Fukuo, Yasuhisa

    2014-01-01

    The Act to Partially Amend the Act on Mental Health and Welfare for the Mentally Disabled was passed on June 13, 2013. Major amendments regarding hospitalization for medical care and protection include the points listed below. The guardianship system will be abolished. Consent by a guardian will no longer be required in the case of hospitalization for medical care and protection. In the case of hospitalization for medical care and protection, the administrators of the psychiatric hospital are required to obtain the consent of one of the following persons: spouse, person with parental authority, person responsible for support, legal custodian, or curator. If no qualified person is available, consent must be obtained from the mayor, etc. of the municipality. The following three obligations are imposed on psychiatric hospital administrators. (1) Assignment of a person, such as a psychiatric social worker, to provide guidance and counseling to patients hospitalized for medical care and protection regarding their postdischarge living environment. (2) Collaboration with community support entities that consult with and provide information as necessary to the person hospitalized, their spouse, a person with parental authority, a person responsible for support, or their legal custodian or curator. (3) Organizational improvements to promote hospital discharge. With regard to requests for discharge, the revised law stipulates that, in addition to the person hospitalized with a mental disorder, others who may file a request for discharge with the psychiatric review board include: the person's spouse, a person with parental authority, a person responsible for support, or their legal custodian or curator. If none of the above persons are available, or if none of them are able to express their wishes, the mayor, etc. of the municipality having jurisdiction over the place of residence of the person hospitalized may request a discharge. In order to promote transition to life in the

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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…

  11. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Science.gov (United States)

    2010-07-01

    ... access to their medical, psychiatric or psychological testing records by writing to: Information and.../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,...

  12. Should medical students track former patients in the electronic health record? An emerging ethical conflict.

    Science.gov (United States)

    Brisson, Gregory E; Neely, Kathy Johnson; Tyler, Patrick D; Barnard, Cynthia

    2015-08-01

    Medical students are increasingly using electronic health records (EHRs) in clerkships, and medical educators should seek opportunities to use this new technology to improve training. One such opportunity is the ability to "track" former patients in the EHR, defined as following up on patients in the EHR for educational purposes for a defined period of time after they have left one's direct care. This activity offers great promise in clinical training by enabling students to audit their diagnostic impressions and follow the clinical history of illness in a manner not possible in the era of paper charting. However, tracking raises important questions about the ethical use of protected health information, including concerns about compromising patient autonomy, resulting in a conflict between medical education and patient privacy. The authors offer critical analysis of arguments on both sides and discuss strategies to balance the ethical conflict by optimizing outcomes and mitigating harms. They observe that tracking improves training, thus offering long-lasting benefits to society, and is supported by the principle of distributive justice. They conclude that students should be permitted to track for educational purposes, but only with defined limits to safeguard patient autonomy, including obtaining permission from patients, having legitimate educational intent, and self-restricting review of records to those essential for training. Lastly, the authors observe that this conflict will become increasingly important with completion of the planned Nationwide Health Information Network and emphasize the need for national guidelines on tracking patients in an ethically appropriate manner.

  13. [Proposed medical record to be used in rape cases. New diagnostic and medicolegal aspects].

    Science.gov (United States)

    Grassi, A; Fiorani, F; Ferrero, S; Silvestri, A; Agneni, M; Pisani, G

    1997-11-01

    The latest report of 1996 on human development in the UN development programme (UNDP) states that 130,000 women are raped every year in the industrialized countries. Illegal "violation" is defined as the sexual penetration of any orifice of the body without the victim's consent. The doctor's contribution is essential in order to ascertain this offence. It can be divided into two stages: precise and complete (... missing? ...) information regarding the sexual aggression which might have taken the form of rape. Management of a rape case represents an extremely complex undertaking for the doctor since it involves medical and legal aspects and requires a number of interventions that lead to a rational evaluation and appropriate treatment. In this context, the doctor's role is not only to protect the psychophysical integrity of the victim, but also to contribute, following an early diagnosis of sexual aggression, to the identification of the particulars of an offence which still risks remaining unpunished, owing to the difficulty of diagnosis and in spite of the recent enactment of Law no. 66 on 15 February 1996. The medical record proposed by the authors consists of a descriptive anamnestic part and a graphic part, thus making the evaluation of the victim more rapid and precise. The proposed medical record is subdivided into anamnesis, objective examination, psychological examination, laboratory tests, any consultancy requested and therapy.

  14. A critical pathway for electronic medical record selection.

    Science.gov (United States)

    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.

  15. Advancing Primary Care Use of Electronic Medical Records in Canada

    Directory of Open Access Journals (Sweden)

    Jennifer Zelmer

    2014-10-01

    Full Text Available In 2010, the federal government's Economic Action Plan funded Canada Health Infoway to co-invest with provinces, territories, and health care providers in electronic medical records (EMRs in primary care. The goal is to help improve access to care, quality of health services, and productivity of the health system, as well as to deliver economic benefits. The decision to fund EMRs was consistent with a long-term framework for digital health established in consultation with stakeholders across the country, spurred by analysis demonstrating the economic impact of such investments and data on Canada's low rate of EMR use in primary care compared with other countries. The decision reflected widespread public and stakeholder consensus regarding the importance of such investments. EMR adoption has more than doubled since 2006, with evaluations identifying efficiency and patient care benefits (e.g., reduced time managing laboratory test results and fewer adverse drug events in community-based practices. These benefits are expected to rise further as EMR adoption continues to grow and practices gain more experience with their use.

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

    Science.gov (United States)

    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.

  17. Human Rights Disclosure Litigation: Uncovering Invisible Medical Records

    Directory of Open Access Journals (Sweden)

    Ena Chadha

    2010-02-01

    Full Text Available This article examines disclosure process and disclosure jurisprudence in human rights litigation. Based on a study of a decade of human rights disclosure rulings from across the country, this article finds that there have been increasing numbers of disclosure demands in human rights litigation and a substantial number of cases in which the disclosure pertained to personal documents and medical records of human rights claimants. While disclosure applications were adjudicated according to a relevance-confidentiality framework used ostensibly to balance privacy and procedural fairness, in reality significant personal information was disclosed based on assumptions of relevancy and under the guise of neutral labels. A closer examination of the different types of materials sought for disclosure in three employment human rights cases reveals that the medical core of certain records are rendered invisible and thereby open for access when tribunals neglect to look behind document categories and titles. The article concludes that there is heightened vulnerability on the part of persons with disabilities as targets of disclosure demands for their confidential medical information. Cet article examine le processus de divulgation et la jurisprudence sur la divulgation dans le domaine de litiges en rapport avec les droits de la personne. Basé sur une étude d’une dizaine d’années de décisions partout au pays au sujet de la divulgation dans le domaine des droits de la personne, cet article conclut que le nombre de demandes de divulgation dans le domaine de litiges en rapport avec les droits de la personne augmente et que dans un nombre considérable de cas, la divulgation avait rapport à des documents personnels et des dossiers médicaux des réclamants de droits de la personne. Quoique on ait statué au sujet de requêtes de divulgation selon un cadre de pertinence/confidentialité utilisé de toute apparence pour maintenir un équilibre entre le

  18. Confidentiality in preclinical Alzheimer disease studies: when research and medical records meet.

    Science.gov (United States)

    Arias, Jalayne J; Karlawish, Jason

    2014-02-25

    Clinical trials to advance the diagnosis and treatment of Alzheimer disease (AD) may expose research subjects to discrimination risks. An individual enrolled in a research study that uses positive test results from amyloid PET imaging or CSF measures of β-amyloid 42 as inclusion criteria has biomarkers indicative of AD pathology. If insurers and employers learn this information, it could expose subjects to discrimination. Unfortunately, current legal and regulatory mechanisms are not sufficient to protect against harms that have significant consequences for subjects. Existing law that prohibits employment and insurance discrimination based on genetic status does not apply to amyloid biomarkers or any other biomarkers for neurodegenerative diseases. Gaps in legal protections fail to protect research subjects from discrimination by long-term care and disability insurers. This risk is particularly concerning because individuals with AD dementia ultimately need long-term care services. To maximize subject protections and advance valuable research, policymakers, investigators, and research institutions must address shortcomings in the design of the electronic medical record, revise laws to limit discrimination, and develop practices that inform research participants of risks associated with loss of confidentiality.

  19. Electronic Health Records and Cloud based Generic Medical Equipment Interface

    OpenAIRE

    Srivastava, Siddharth; Gupta, Ramji; Rai, Astha; Cheema, A. S.

    2014-01-01

    Now-a-days Health Care industry is well equipped with Medical Equipments to provide accurate and timely reports of investigation and examination results. Medical Equipments available in market are made for specific tests suited for a particular laboratory leading to a wide variety of devices. The result viewing experience on console of these devices is not only cumborsome for medical staff but inefficient. Therefore, Medical Equipment Interfaces act as backbone of any Hospital Management Info...

  20. Evaluation Existential of Medical Record Laboratory at the Diploma 3 Program for Medical Record & Health Information, Mathematics and Natural Science Faculty, Gadjah Mada University

    Directory of Open Access Journals (Sweden)

    Savitri Citra Budi

    2009-06-01

    Evaluation on the existence of laboratory was presumably exploited to consider future development and management as expected that this Laboratory could be taken as example for medical record management in hospitals.

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

    Science.gov (United States)

    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

  2. Evidence for handheld electronic medical records in improving care: a systematic review

    Directory of Open Access Journals (Sweden)

    Straus Sharon E

    2006-06-01

    Full Text Available Abstract Background Handheld electronic medical records are expected to improve physician performance and patient care. To confirm this, we performed a systematic review of the evidence assessing the effects of handheld electronic medical records on clinical care. Methods To conduct the systematic review, we searched MEDLINE, EMBASE, CINAHL, and the Cochrane library from 1966 through September 2005. We included randomized controlled trials that evaluated effects on practitioner performance or patient outcomes of handheld electronic medical records compared to either paper medical records or desktop electronic medical records. Two reviewers independently reviewed citations, assessed full text articles and abstracted data from the studies. Results Two studies met our inclusion criteria. No other randomized controlled studies or non-randomized controlled trials were found that met our inclusion criteria. Both studies were methodologically strong. The studies examined changes in documentation in orthopedic patients with handheld electronic medical records compared to paper charts, and both found an increase in documentation. Other effects noted with handheld electronic medical records were an increase in time to document and an increase in wrong or redundant diagnoses. Conclusion Handheld electronic medical records may improve documentation, but as yet, the number of studies is small and the data is restricted to one group of patients and a small group of practitioners. Further study is required to determine the benefits with handheld electronic medical records especially in assessing clinical outcomes.

  3. Paper-Based Medical Records: the Challenges and Lessons Learned from Studying Obstetrics and Gynaecological Post-Operation Records in a Nigerian Hospital

    Directory of Open Access Journals (Sweden)

    Adekunle Yisau Abdulkadir

    2010-10-01

    Full Text Available AIM: With the background knowledge that auditing of Medical Records (MR for adequacy and completeness is necessary if it is to be useful and reliable in continuing patient care; protection of the legal interest of the patient, physicians, and the Hospital; and meeting requirements for researches, we scrutinized theatre records of our hospital to identify routine omissions or deficiencies, and correctable errors in our MR system. METHOD: Obstetrics and Gynaecological post operation theatre records between January 2006 and December 2008 were quantitatively and qualitatively analyzed for details that included: hospital number; Patients age; diagnosis; surgery performed; types and modes of anesthesia; date of surgery; patients’ ward; Anesthetists names; surgeons and attending nurses names, and abbreviations used with SPSS 15.0 for Windows. RESULTS: Hardly were any of the 1270 surgeries during the study period documented without an omission or an abbreviation. Hospital numbers and patients’ age were not documented in 21.8% (n=277 and 59.1% (n=750 respectively. Diagnoses and surgeries were recorded with varying abbreviations in about 96% of instances. Surgical team names were mostly abbreviated or initials only given. CONCLUSION: To improve the quality of Paper-based Medical Record, regular auditing, training and good orientation of medical personnel for good record practices, and discouraging large volume record book to reduce paper damages and sheet loss from handling are necessary else what we record toady may neither be useful nor available tomorrow. [TAF Prev Med Bull 2010; 9(5.000: 427-432

  4. Security protection of DICOM medical images using dual-layer reversible watermarking with tamper detection capability.

    Science.gov (United States)

    Tan, Chun Kiat; Ng, Jason Changwei; Xu, Xiaotian; Poh, Chueh Loo; Guan, Yong Liang; Sheah, Kenneth

    2011-06-01

    Teleradiology applications and universal availability of patient records using web-based technology are rapidly gaining importance. Consequently, digital medical image security has become an important issue when images and their pertinent patient information are transmitted across public networks, such as the Internet. Health mandates such as the Health Insurance Portability and Accountability Act require healthcare providers to adhere to security measures in order to protect sensitive patient information. This paper presents a fully reversible, dual-layer watermarking scheme with tamper detection capability for medical images. The scheme utilizes concepts of public-key cryptography and reversible data-hiding technique. The scheme was tested using medical images in DICOM format. The results show that the scheme is able to ensure image authenticity and integrity, and to locate tampered regions in the images.

  5. Discrepancies Between Medical and Pharmacy Records for Patients on Anti-HIV Drugs

    NARCIS (Netherlands)

    de Maat, Monique M R; Frankfort, Suzanne V; Mathôt, Ron A A; Mulder, Jan W; Meenhorst, Pieter L; van Gorp, Eric C M; Koks, Cornelis H W; Hoetelmans, Richard M W; de Boer, Anthonius; Beijnen, Jos H

    2002-01-01

    OBJECTIVE: To compare and evaluate drug notations in outpatient medical records and in pharmacy records in a cohort of HIV-1-infected patients treated with antiretroviral drugs. METHODS: Data on 103 patients were obtained from January 1, 1998, through December 31, 1999, by medical chart review and

  6. Discrepancies Between Medical and Pharmacy Records for Patients on Anti-HIV Drugs

    NARCIS (Netherlands)

    de Maat, Monique M R; Frankfort, Suzanne V; Mathôt, Ron A A; Mulder, Jan W; Meenhorst, Pieter L; van Gorp, Eric C M; Koks, Cornelis H W; Hoetelmans, Richard M W; de Boer, Anthonius; Beijnen, Jos H

    2002-01-01

    OBJECTIVE: To compare and evaluate drug notations in outpatient medical records and in pharmacy records in a cohort of HIV-1-infected patients treated with antiretroviral drugs. METHODS: Data on 103 patients were obtained from January 1, 1998, through December 31, 1999, by medical chart review and c

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

    Science.gov (United States)

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Access to medical and psychological records. 324.13 Section 324.13 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) PRIVACY PROGRAM DFAS PRIVACY ACT PROGRAM Individual Access to Records § 324.13 Access to medical and psychological...

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

    Science.gov (United States)

    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.

  9. Research on Supporting Functions of the Information Technology on Electronic medical record

    Directory of Open Access Journals (Sweden)

    Hu Sheng Li

    2016-01-01

    Full Text Available Objective: Promote further utilization of information technology in quality control of the electronic medical record and provide forceful technological supports for medical quality control. Method: research existing problems in quality control of electronic medical record at present, put forward that the information technology should be used sufficiently, integration with other systems should be completed, quality control rules should be built and quality control time should be set and finally point out the key construction element of information technology to provide supports. Result: the article points out that further utilization of information technology in quality control of EMR should start from the standard, structuralized and paperless electronic medical record, construction of the communication platform and application of high technology. Conclusion: it is of great significance to promote improvement of quality control level of the electronic medical record and improve continuously medical quality.

  10. Health care consumer's perception of the Electronic Medical Record ...

    African Journals Online (AJOL)

    However, no research has been described in the literature regarding the user's perception of the clinical electronic medical ... Method: A structured questionnaire was developed, validated and utilized in this quantitative research project.

  11. 32 CFR 319.7 - Special procedures: Medical records.

    Science.gov (United States)

    2010-07-01

    ... (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures: Medical..., have an adverse effect on the physical or mental health or safety and welfare of the requester or...

  12. Corridor consultations and the medical microbiological record: is patient safety at risk?

    OpenAIRE

    Heard, S R; Roberts, C; Furrows, S J; Kelsey, M.; Southgate, L

    2003-01-01

    The performance procedures of the General Medical Council are aimed at identifying seriously deficient performance in a doctor. The performance procedures require the medical record to be of a standard that enables the next doctor seeing the patient to give adequate care based on the available information. Setting standards for microbiological record keeping has proved difficult. Over one fifth of practising medical microbiologists (including virologists) in the UK (139 of 676) responded to a...

  13. A Model for Protective Behavior against the Harmful Effects of Radiation based on Medical Institution Classifications

    Energy Technology Data Exchange (ETDEWEB)

    Han, Eun Ok; Kwon, Deok Mun [Daegu Health College, Daegu (Korea, Republic of); Dong, Kyung Rae [Gwangju Health College University, Gwangju (Korea, Republic of); Han, Seung Moo [Kyung Hee University, Seoul (Korea, Republic of)

    2010-12-15

    This study surveyed a total of 1,322 radiation technologist in health care institutions throughout Korea. This is a comparative study conducted on the levels of protective behavior against the harmful effects of radiation in heath care institutions which indicated that university hospitals and general hospitals showed higher level of protective behavior than for medical practitioners. This study found university hospitals have the following 7 characteristics to manage protective behavior against the harmful effects of radiation, protective environment, self-efficacy by distinction of task , self-efficacy, expectation of the protective behavior, the number of patients, level of the education related to the protection of the harmful effects of radiation and protective attitude. While general hospitals have the following 3 characteristics protective environment, expectation of the protective behavior and protective attitude. Hospitals have the following 4 characteristics protective environment, expectation of the protective behavior, protective attitude and self-efficacy and medical clinics have characteristics protective environment.

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  16. 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

    Science.gov (United States)

    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…

  17. Poor awareness of preventing aspirin-induced gastrointestinal injury with combined protective medications.

    Science.gov (United States)

    Zhu, Ling-Ling; Xu, Ling-Cheng; Chen, Yan; Zhou, Quan; Zeng, Su

    2012-06-28

    To investigate prescribing pattern in low-dose aspirin users and physician awareness of preventing aspirin-induced gastrointestinal (GI) injury with combined protective medications. A retrospective drug utilization study was conducted in the 2nd Affiliated Hospital, School of Medicine, Zhejiang University. The hospital has 2300 beds and 2.5 million outpatient visits annually. Data mining was performed on all aspirin prescriptions for outpatients and emergency patients admitted in 2011. Concomitant use of proton-pump inhibitors (PPIs), histamine 2-receptor antagonists (H2RA) and mucoprotective drugs (MPs) were analyzed. A defined daily dose (DDD) methodology was applied to each MP. A further investigation was performed in aspirin users on combination use of GI injurious medicines [non-steoid anti-inflammatory drugs (NSAIDs), corticosteroids and clopidogrel and warfarin] or intestinal protective drugs (misoprostol, rebamipide, teprenone and gefarnate). Data of major bleeding episodes were derived from medical records and adverse drug reaction monitoring records. The annual incidence of major GI bleeding due to low-dose aspirin was estimated for outpatients. Prescriptions for aspirin users receiving PPIs, H2RA and MPs (n = 1039) accounted for only 3.46% of total aspirin prescriptions (n = 30 015). The ratios of coadministration of aspirin/PPI, aspirin/H2RA, aspirin/MP and aspirin/PPI/MP to the total aspirin prescriptions were 2.82%, 0.12%, 0.40% and 0.12%, respectively. No statistically significant difference was observed in age between patients not receiving any GI protective medications and patients receiving PPIs, H2RA or MPs. The combined medication of aspirin and PPI was used more frequently than that of aspirin and MPs (2.82% vs 0.40%, P teprenone > sucralfate oral suspension > L-glutamine and sodium gualenate granules > rebamipide > sucralfate chewable tablets. The ratio of MP plus aspirin prescriptions to the total MP prescriptions was as follows: rebamipide

  18. Poor awareness of preventing aspirin-induced gastrointestinal injury with combined protective medications

    Institute of Scientific and Technical Information of China (English)

    Ling-Ling Zhu; Ling-Cheng Xu; Yan Chen; Quan Zhou; Su Zeng

    2012-01-01

    AIM:To investigate prescribing pattern in low-dose aspirin users and physician awareness of preventing aspirin-induced gastrointestinal (GI) injury with combined protective medications.METHODS:A retrospective drug utilization study was conducted in the 2nd Affiliated Hospital,School of Medicine,Zhejiang University.The hospital has 2300 beds and 2.5 million outpatient visits annually.Data mining was performed on all aspirin prescriptions for outpatients and emergency patients admitted in 2011.Concomitant use of proton-pump inhibitors (PPIs),histamine 2-receptor antagonists (H2RA) and mucoprotective drugs (MPs) were analyzed.A defined daily dose (DDD) methodology was applied to each MP.A further investigation was performed in aspirin users on combination use of GI injurious medicines [non-steoid anti-inflammatory drugs (NSAIDs),corticosteroids and clopidogrel and warfarin] or intestinal protective drugs (misoprostol,rebamipide,teprenone and gefarnate).Data of major bleeding episodes were derived from medical records and adverse drug reaction monitoring records.The annual incidence of major GI bleeding due to low-dose aspirin was estimated for outpatients.RESULTS:Prescriptions for aspirin users receiving PPIs,H2RA and MPs (n =1039) accounted for only 3.46%of total aspirin prescriptions (n =30 015).The ratios of coadministration of aspirin/PPI,aspirin/H2RA,aspirin/MP and aspirin/PPI/MP to the total aspirin prescriptions were 2.82%,0.12%,0.40% and 0.12%,respectively.No statistically significant difference was observed in age between patients not receiving any GI protective medications and patients receiving PPIs,H2RA or MPs.The combined medication of aspirin and PPI was used more frequently than that of aspirin and MPs (2.82% vs 0.40%,P < 0.05) and aspirin/H2RA (2.82% vs 0.12%,P < 0.05).The values of DDDs of MPs in descending order were as follows:gefarnate,hydrotalcite > teprenone > sucralfate oral suspension > L-glutamine and sodium

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

    OpenAIRE

    Zhu, Xinxin; Cimin, James J.

    2013-01-01

    Each year thousands of patients die of avoidable medication errors. When a patient is admitted to, transferred within, or discharged from a clinical facility, clinicians should review previous medication orders, current orders and future plans for care, and reconcile differences if there are any. If medication reconciliation is not accurate and systematic, medication errors such as omissions, duplications, dosing errors, or drug interactions may occur and cause harm. Computer-assisted medicat...

  20. Health Care Professionals’ Pain Narratives in Hospitalized Children’s Medical Records. Part 1: Pain Descriptors

    Directory of Open Access Journals (Sweden)

    Judy Rashotte

    2013-01-01

    Full Text Available BACKGROUND: Although documentation of children’s pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children.

  1. Validity of a hospital-based obstetric register using medical records as reference

    DEFF Research Database (Denmark)

    Brixval, Carina Sjöberg; Thygesen, Lau Caspar; Johansen, Nanna Roed;

    2015-01-01

    and validity of a hospital-based clinical register - the Obstetric Database - using a national register and medical records as references. METHODS: We assessed completeness of a hospital-based clinical register - the Obstetric Database - by linking data from all women registered in the Obstetric Database...... as having given birth in 2013 to the National Patient Register with coverage of all births in 2013. Validity of eleven selected indicators from the Obstetric Database was assessed using medical records as a golden standard. Using a random sample of 250 medical records, we calculated proportion of agreement......, sensitivity, specificity, and positive and negative predictive values for each indicator. Two assessors independently reviewed medical records and inter-rater reliability was calculated as proportion of agreement and Cohen's κ coefficient. RESULTS: We found 100% completeness of the Obstetric Database when...

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

    Science.gov (United States)

    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.

  3. The work practice of medical secretaries and the implementation of electronic health records in Denmark

    DEFF Research Database (Denmark)

    Bertelsen, Pernille; Nøhr, Christian

    2005-01-01

    The introduction of electronic health records will entail substantial organisational changes to the clinical and administrative staff in hospitals. Hospital owners in Denmark have predicted that these changes will render up to half of medical secretaries redundant. The present study however shows...... that clinicians as well as nurses depend on medical secretaries, and therefore to reduce the number of secretaries because electronic health record systems are implemented needs very careful thinking, planning and discussion with the other professions involved....

  4. Evidence for handheld electronic medical records in improving care: a systematic review

    OpenAIRE

    Straus Sharon E; Wu Robert C

    2006-01-01

    Abstract Background Handheld electronic medical records are expected to improve physician performance and patient care. To confirm this, we performed a systematic review of the evidence assessing the effects of handheld electronic medical records on clinical care. Methods To conduct the systematic review, we searched MEDLINE, EMBASE, CINAHL, and the Cochrane library from 1966 through September 2005. We included randomized controlled trials that evaluated effects on practitioner performance or...

  5. [Quality of medical records in Naples (Italy) 2nd University School of Medicine].

    Science.gov (United States)

    Agozzino, E; Esposito, S; Parmeggiani, C; Piro, A; Grippo, N; Di Palma, M A

    2008-01-01

    To evaluate and improve the quality of medical-record keeping, in clinics and surgery departments. The evaluation involved 66 Operative Units (O.U.) of the "2nd University Hospital" in Naples (Italy). 10 medical records for each O.U. were randomly selected, for a total of 660. The quality was evaluated in all sections of medical records using the criteria of completeness, clarity and traceability of the data. The most critical issues are: unclear handwriting in almost all sections, in the whole scarse presence of a discharge letter (17.0%) in surgery (1.4%), almost total absence of the physicians signature in the clinical diary (2.3%). The completeness of medical records (presence of patient's history, physical examination, informed consent) is significantly higher in the surgery departments. The medical records are significantly righter in the clinic departments. In general, a poor quality of medical-record keeping was detected. This indicates the need to improve the quality by involving the staff in the importance of correct compilation.

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

    Science.gov (United States)

    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

  7. Data Transmission and Access Protection of Community Medical Internet of Things

    Directory of Open Access Journals (Sweden)

    Xunbao Wang

    2017-01-01

    Full Text Available On the basis of Internet of Things (IoT technologies, Community Medical Internet of Things (CMIoT is a new medical information system and generates massive multiple types of medical data which contain all kinds of user identity data, various types of medical data, and other sensitive information. To effectively protect users’ privacy, we propose a secure privacy data protection scheme including transmission protection and access control. For the uplink transmission data protection, bidirectional identity authentication and fragmented multipath data transmission are used, and for the downlink data protection, fine grained access control and dynamic authorization are used. Through theoretical analysis and experiment evaluation, it is proved that the community medical data can be effectively protected in the transmission and access process without high performance loss.

  8. A retrospective cohort study on lifestyle habits of cardiovascular patients: how informative are medical records?

    NARCIS (Netherlands)

    Fouwels, A.J.; Bredie, S.J.H.; Wollersheim, H.; Schippers, G.M.

    2009-01-01

    ABSTRACT: BACKGROUND: To evaluate the vigilance of medical specialists as to the lifestyle of their cardiovascular outpatients by comparing lifestyle screening as registered in medical records versus a lifestyle questionnaire (LSQ), a study was carried out at the cardiovascular outpatient clinic of

  9. 32 CFR 1901.31 - Special procedures for medical and psychological records.

    Science.gov (United States)

    2010-07-01

    ... 32 National Defense 6 2010-07-01 2010-07-01 false Special procedures for medical and psychological records. 1901.31 Section 1901.31 National Defense Other Regulations Relating to National Defense CENTRAL INTELLIGENCE AGENCY PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters § 1901.31 Special procedures for medical...

  10. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Science.gov (United States)

    2010-10-01

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

  11. Admission medical records made at night time have the same quality as day and evening time

    DEFF Research Database (Denmark)

    Amirian, Ilda; Mortensen, Jacob F; Rosenberg, Jacob

    2014-01-01

    during day, evening and night time. MATERIAL AND METHODS: A total of 1,000 admission medical records were collected from 2009 to 2013 based equally on four diagnoses: mechanical bowel obstruction, appendicitis, gallstone disease and gastrointestinal bleeding. The records were reviewed for errors by a pre...

  12. The EMR-scan: assessing the quality of Electronic Medical Records in general practice.

    NARCIS (Netherlands)

    Verheij, R.; Jabaaij, L.; Njoo, K.; Hoogen, H. van den; Bakker, D. de

    2008-01-01

    Background: The use of electronic medical records (EMR) in general practice has spread rapidly in the last decade (more than 90% today). Traditionally, these records are primarily used for direct patient care and for administrative purposes by the practice involved. In recent years, further technica

  13. The use of open source electronic medical records in an urban ED in Kumasi-Ghana

    Directory of Open Access Journals (Sweden)

    P.K. Forson*

    2013-12-01

    Conclusion: Open source medical records may be the most appropriate and cost-effective software to adapt for keeping patient records electronically in a low resource setting. Further studies need to be conducted to demonstrate how EMR may affect the pace of work in the ED.

  14. OPTIMAL DESIGN ALGORITHM FOR FAULT TOLERANT INFORMATION SYSTEMS USED FOR PROCESSING ELECTRONIC MEDICAL RECORDS

    Directory of Open Access Journals (Sweden)

    P. V. Melyushin

    2014-01-01

    Full Text Available The paper considers problems on designing of medical information systems and proposes an approach to creation of a highly reliable automated system for processing electronic medical records on the basis of file allocation optimization in the network nodes. A mathematical model has been developed for optimal distribution of the files in the network nodes and an experimental investigation of two schemes of medical information systems has been executed in the paper.

  15. Legal aspects regarding the use and integration of electronic medical records for epidemiological purposes with focus on the Italian situation

    Directory of Open Access Journals (Sweden)

    Antonietta Stendardo

    2013-09-01

    Full Text Available The "Observational Studies" working group of the Italian Association of Medical Statistics and Clinical Epidemiology (SISMEC has undertaken to study the impact of recent healthcare sector regulations on the legal and organisational aspects of managing all EMR databases with emphasis on Legislative Decree No. 196/2003 (the Italian Personal Data Protection Law. This paper examines six issues relating to theirs legal implications. The first section, “Confidentiality”, provides definitions and the regulatory context for the terms "confidentiality" and "personal data". In the second, “Nature of data held in electronic medical record archives”, we discuss the problem of sensitive data and procedures to make the identification code anonymous. In “Data ownership” we highlight the difference between the data controller and the database controller. The fourth section, “Conditions for processing”, discusses problems associated with using research data from one study in other investigations. In the fifth, “Patient consent”, we address the problems related to patient consent. Finally in “Penalties” we outline the main civil and criminal liability issues applied in case of non-compliance with the provisions of the Personal Data Protection Code. Where possible, we provide suggestions on how to comply with the legal requirements of managing medical record archives in order to make it easier for researchers to remain in compliance with the relevant provisions. 

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

    Science.gov (United States)

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

    2016-01-01

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

  17. Health information technology: medical record documentation issues in the electronic era.

    Science.gov (United States)

    Dacey, Bill; Bholat, Michelle Anne

    2012-12-01

    This article outlines the regulatory movement propelling physicians into the electronic health record environment and the subsequent emergence of quality issues in the medical record. There are benefits and downside risks for implementing electronic health records as part of the desire of a practice or institution to build patient-centered medical homes. The intersection of how a practice or institution collects and reports quality metrics using health information technology and subsequently submits claims for services rendered has created unforeseen challenges for which leadership must be aware and address proactively.

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

    Science.gov (United States)

    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.

  19. Towards improvement of the accuracy and completeness of medication registration with the use of an electronic medical record (EMR)

    NARCIS (Netherlands)

    Hiddema-van de Wal, A; Smith, RJA; van der Werf, GT; Meyboom-de Jong, B

    2001-01-01

    Background. Approximately 80% of GPs use a GP information system (GIS) and an electronic medical record (EMR) in their daily practice. To reap the full benefits of an EMR for patient care, post-graduate education and research, the data input must be well structured and accurately coded. Objectives.

  20. Towards improvement of the accuracy and completeness of medication registration with the use of an electronic medical record (EMR)

    NARCIS (Netherlands)

    Hiddema-van de Wal, A; Smith, RJA; van der Werf, GT; Meyboom-de Jong, B

    2001-01-01

    Background. Approximately 80% of GPs use a GP information system (GIS) and an electronic medical record (EMR) in their daily practice. To reap the full benefits of an EMR for patient care, post-graduate education and research, the data input must be well structured and accurately coded. Objectives.

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

    Energy Technology Data Exchange (ETDEWEB)

    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.

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

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

    Science.gov (United States)

    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.

  5. Readiness of Shiraz teaching hospitals to implement Electronic Medical Record (EMR

    Directory of Open Access Journals (Sweden)

    Ali Garavand

    2016-07-01

    Full Text Available Introduction: Due to the importance of Electronic Medical Record (EMR in the quality of health care services, checking the readiness of hospitals to implement it is a vital step to define success or failure of the Electronic Medical Record in the first place. The aim of this study was to evaluate the readiness of Shiraz teaching hospitals to implement Electronic Medical Record. Method: This study was a cross-sectional descriptive study done in 2015. The study population included Health Information Management (HIM staff of Shiraz teaching hospitals. Five hospitals from a total of 14 hospitals were selected as Single-stage cluster sampling with a population of 79 health information management staff. Data collection was performed by using a validated questionnaire. The questionnaire consisted of three main dimensions including technical, organizational and legal requirements. For data analysis, SPSS software version 16 and one way Analysis of Variance (ANOVA for comparisons between five hospitals were used. Results:The results showed that Shiraz teaching hospitals have high readiness (3.66 out of 5 to implement Electronic Medical Record. Shiraz teaching hospitals are better prepared in terms of legal requirements. Also, a significant difference was not observed among the hospitals in any of the technical, organizational and legal aspects (P > 0.05. Conclusion: Due to the importance of the technical, organizational and legal aspects in the implementation of Electronic Medical Record, it is recommended that the authorities consider these aspects in implementation of Electronic Medical Record. Also, according to the high readiness of Shiraz teaching hospitals to implement Electronic Medical Record, it is recommended that authorities should take necessary measures, including financial support in order to run it.

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

    Science.gov (United States)

    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.

  7. Comparison of birth weight between school health records and medical birth records in Denmark

    DEFF Research Database (Denmark)

    Jensen, Camilla Bjørn; Gamborg, Michael; Heitmann, Berit

    2015-01-01

    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. RESULTS: 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...

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

    Science.gov (United States)

    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

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

    Science.gov (United States)

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

    Science.gov (United States)

    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.

  11. 34 CFR 75.740 - Protection of and access to student records; student rights in research, experimental programs...

    Science.gov (United States)

    2010-07-01

    ... 34 Education 1 2010-07-01 2010-07-01 false Protection of and access to student records; student... Grantee? Privacy § 75.740 Protection of and access to student records; student rights in research, experimental programs, and testing. (a) Most records on present or past students are subject to...

  12. 34 CFR 76.740 - Protection of and access to student records; student rights in research, experimental programs...

    Science.gov (United States)

    2010-07-01

    ... 34 Education 1 2010-07-01 2010-07-01 false Protection of and access to student records; student... of the State and Its Subgrantees? Privacy § 76.740 Protection of and access to student records; student rights in research, experimental programs, and testing. (a) Most records on present or...

  13. Obligations and responsibilities in radiation protection in the medical field; Obligations et responsabilites en radioprotection dans le domaine medical

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2011-07-01

    This document briefly presents the various obligations and responsibilities of the various actors involved in or concerned by radiation protection in the medical field: the hospital administration (with respect to workers and patients), the physician (authorization and declaration, justification, optimization), the medical electro-radiology operator, the person with expertise in medical radio-physics (PSRPM), the radio-pharmacist (he is required in nuclear medicine with internal use of pharmaceutical product), the personnel with expertise in radiation protection (PCR), and other health professionals

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

    Science.gov (United States)

    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.

  15. 病历书写的临床教学%Clinical Teaching in Medical Records Writing

    Institute of Scientific and Technical Information of China (English)

    马云波; 刘怀戈

    2011-01-01

    病历书写是临床所有专业医师必备的基本技能之一,如何使病历书写的临床教学,在依据教学大纲的前提下,必须以符合国家和卫生部等相关法律法规为根本,与临床实践紧密结合,抓住教学中主要诊断的选择、危重疑难病案、围手术期病历书写等重点和难点问题,努力克服教学与临床工作中的反差,不断提高病历书写的教学质量.%Medical records writing is one of basic skills that are essential to all the clinical professional doctors. Under the premise of teaching outline, how to make clinical teaching of medical records writing overcomes contrast between teaching and clinical work and improves teaching quality in medical records writting, as the basis of according with related law sand regulations of country and ministry of health, closely com bing with clinical practice, grabbing the key points and difficult points of choice about main diagnosis, critical and difficult medical records, medical records writing of perioperative period in teaching.

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    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.

  18. IT Challenges for Space Medicine or How do We Protect Medical Information and Still Get Useful Work Done?

    Science.gov (United States)

    Johnson-Throop, Kathy A.

    2010-01-01

    Space Medicine provides healthcare services of various types for astronauts throughout their lifetime starting from the time they are selected as astronauts. IT challenges include: protection of private medical information, access from locations both inside and outside NASA, nearly 24x7 access, access during disasters, international partner access, data archiving, off-region backup, secure communication of medical data to people outside the NASA system (e.g. expert consultants), efficient movement of medical record information between locations, search and retrieval of relevant information, and providing all of these services/capabilities within a limited budget. In Space Medicine, we have provided for these in various ways: limit the amount of private medical information stored locally, utilize encryption mechanisms that the international partners can also use, utilize 2-factor authentication, virtualize servers, employ concept-based search, and use of standardized terminologies (SNOMED) and messaging (HL7).

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

    Science.gov (United States)

    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.

  20. Barriers to retrieving patient information from electronic health record data: failure analysis from the TREC Medical Records Track.

    Science.gov (United States)

    Edinger, Tracy; Cohen, Aaron M; Bedrick, Steven; Ambert, Kyle; Hersh, William

    2012-01-01

    Secondary use of electronic health record (EHR) data relies on the ability to retrieve accurate and complete information about desired patient populations. The Text Retrieval Conference (TREC) 2011 Medical Records Track was a challenge evaluation allowing comparison of systems and algorithms to retrieve patients eligible for clinical studies from a corpus of de-identified medical records, grouped by patient visit. Participants retrieved cohorts of patients relevant to 35 different clinical topics, and visits were judged for relevance to each topic. This study identified the most common barriers to identifying specific clinic populations in the test collection. Using the runs from track participants and judged visits, we analyzed the five non-relevant visits most often retrieved and the five relevant visits most often overlooked. Categories were developed iteratively to group the reasons for incorrect retrieval for each of the 35 topics. Reasons fell into nine categories for non-relevant visits and five categories for relevant visits. Non-relevant visits were most often retrieved because they contained a non-relevant reference to the topic terms. Relevant visits were most often infrequently retrieved because they used a synonym for a topic term. This failure analysis provides insight into areas for future improvement in EHR-based retrieval with techniques such as more widespread and complete use of standardized terminology in retrieval and data entry systems.

  1. Evaluation of medication errors with implementation of electronic health record technology in the medical intensive care unit

    Directory of Open Access Journals (Sweden)

    Liao TV

    2017-05-01

    Full Text Available T Vivian Liao,1 Marina Rabinovich,2 Prasad Abraham,2 Sebastian Perez,3 Christiana DiPlotti,4 Jenny E Han,5 Greg S Martin,5 Eric Honig5 1Department of Pharmacy Practice, College of Pharmacy, Mercer Health Sciences Center, 2Department of Pharmacy and Clinical Nutrition, Grady Health System, 3Department of Surgery, Emory University, 4Pharmacy, Ingles Markets, 5Department of Medicine, Emory University, Atlanta, GA, USA Purpose: Patients in the intensive care unit (ICU are at an increased risk for medication errors (MEs and adverse drug events from multifactorial causes. ME rate ranges from 1.2 to 947 per 1,000 patient days in the medical ICU (MICU. Studies with the implementation of electronic health records (EHR have concluded that it significantly reduced overall prescribing errors and the number of errors that caused patient harm decreased. However, other types of errors, such as wrong dose and omission of required medications increased after EHR implementation. We sought to compare the number of MEs before and after EHR implementation in the MICU, with additional evaluation of error severity.Patients and methods: Prospective, observational, quality improvement study of all patients admitted to a single MICU service at an academic medical center. Patients were evaluated during four periods over 2 years: August–September 2010 (preimplementation; period I, January–February 2011 (2 months postimplementation; period II, August–September 2012 (21 months postimplementation; period III, and January–February 2013 (25 months postimplementation; period IV. All medication orders and administration records were reviewed by an ICU clinical pharmacist and ME was defined as a deviation from established standards for prescribing, dispensing, administering, or documenting medication. The frequency and classification of MEs were compared between groups by chi square; p<0.05 was considered significant.Results: There was a statistically significant increase

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

    Science.gov (United States)

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

    2015-09-01

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

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

    Science.gov (United States)

    Wilhoit, Kathryn; Mustain, Jane; King, Marjorie

    2006-01-01

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

  4. Similarities and differences of doctor-patient co-operated evidence-based medical record of treating digestive system diseases with integrative medicine compared with traditional medical records

    Institute of Scientific and Technical Information of China (English)

    Bo Li; Wen-Hong Shao; Yan-Da Li; Ying-Pan Zhao; Qing-Na Li; Zhao Yang; Hong-Cai Shang

    2016-01-01

    Objective: To establish the model of doctor-patient cooperated record, based on the concepts of narrative evidence-based medicine and related theories on Doctor-Patient Co-operated Evidence-Based Medical Record. Methods: We conducted a literature search from Pubmed, following the principles of narrative evidence-based medicine, and refer to the advice of experts of digestive system and EBM in both traditional Chinese medicine and Western medicine. Result: This research is a useful attempt to discuss the establishment of doctor-patient co-operated evidence-based medical record guided by narrative evidence-based medicine. Conclusion:Doctor-patient co-operated medical record can become a key factor of the curative effect evaluation methodology system of integrated therapy of tradition Chinese medicine and Western medicine on spleen and stomach diseases.%遵循叙事循证医学理念,咨询中西医消化内科及循证医学专家,凝练医患共建式病历的理论,建立医患共建式病历的范本,对比医患共建式病历与传统病历记录的不同,分析医患共建式病历的优缺点。思考与展望:医患共建式病历有可能成为中西医合作治疗脾胃病疗效评价方法学体系的一个要素。

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

    Science.gov (United States)

    Liu, Baozhen; Liu, Zhiguo; Wang, Xianwen

    2015-06-01

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

  6. Discovering medical conditions associated with periodontitis using linked electronic health records

    Science.gov (United States)

    Boland, Mary Regina; Hripcsak, George; Albers, David J.; Wei, Ying; Wilcox, Adam B.; Wei, Jin; Li, Jianhua; Lin, Steven; Breene, Michael; Myers, Ronnie; Zimmerman, John; Papapanou, Panos N.; Weng, Chunhua

    2013-01-01

    Aim To use linked electronic medical and dental records to discover associations between periodontitis and medical conditions independent of a priori hypotheses. Materials and Methods This case-control study included 2475 patients who underwent dental treatment at the College of Dental Medicine at Columbia University and medical treatment at NewYork-Presbyterian Hospital. Our cases are patients who received periodontal treatment and our controls are patients who received dental maintenance but no periodontal treatment. Chi-square analysis was performed for medical treatment codes and logistic regression was used to adjust for confounders. Results Our method replicated several important periodontitis associations in a largely Hispanic population, including diabetes mellitus type I (OR = 1.6, 95% CI 1.30–1.99, p diabetes, obesity, lipid and circulatory system conditions, alcohol and tobacco abuse. Conclusions This study contributes a high-throughput method for associating periodontitis with systemic diseases using linked electronic records. PMID:23495669

  7. On-the-job training of health professionals for electronic health record and electronic medical record use: A scoping review

    Directory of Open Access Journals (Sweden)

    Valentina L. Younge

    2015-09-01

    Full Text Available The implementation of electronic health records (EHRs or electronic medical records (EMRs is well documented in health informatics literature yet, very few studies focus primarily on how health professionals in direct clinical care are trained for EHR or EMR use. Purpose: To investigate how health professionals in direct clinical care are trained to prepare them for EHR or EMR use. Methods: Systematic searches were conducted in CINAHL, EMBASE, Ovid MEDLINE, PsycINFO, PubMed and ISI WoS and, the Arksey and O’Malley scoping methodological framework was used to collect the data and analyze the results. Results: Training was done at implementation, orientation and post-implementation. Implementation and orientation training had a broader scope while post-implementation training focused on proficiency, efficiency and improvement. The multiplicity of training methods, types and levels of training identified appear to suggest that training is more effective when a combination of training methods are used.

  8. Applying the theory of constraints to the logistics service of medical records of a hospital

    Directory of Open Access Journals (Sweden)

    Víctor-G. Aguilar-Escobar

    2016-09-01

    Full Text Available Management of patient records in a hospital is of major importance, for its impact both on the quality of care and on the associated costs. Since this process is circular, the prevention of the building up of bottlenecks is especially important. Thus, the objective of this paper was to analyze whether the Theory of Constraints (TOC can be useful to the logistics of medical records in hospitals. The paper is based on a case study conducted about the 2007-2011 period in the Medical Records Logistics Service at the Hospital Universitario Virgen Macarena in Seville (Spain. From April 2008, a set of actions in the clinical record logistics system were implemented based on the application of TOC principles. The results obtained show a significant increase in the level of service and employee productivity, as well as a reduction of cost and the number of patients’ complaints.

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

    Science.gov (United States)

    Jeanty, C

    1978-12-01

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

  10. Invite yourself to the table: librarian contributions to the electronic medical record.

    Science.gov (United States)

    Brandes, Susan; Wells, Karen; Bandy, Margaret

    2013-01-01

    Librarians from Exempla Healthcare hospitals initiated contact with the chief medical information officer regarding evidence-based medicine activities related to the development of the system's Electronic Medical Record (EMR). This column reviews the librarians' involvement in specific initiatives that included providing comparative information on point-of-care resources to integrate into the EMR, providing evidence as needed for the order sets being developed, and participating with clinicians on an evidence-based advisory committee.

  11. Perspectives of healthcare practitioners: An exploration of interprofessional communication using electronic medical records.

    Science.gov (United States)

    Bardach, Shoshana H; Real, Kevin; Bardach, David R

    2017-05-01

    Contemporary state-of-the-art healthcare facilities are incorporating technology into their building design to improve communication and patient care. However, technological innovations may also have unintended consequences. This study seeks to better understand how technology influences interprofessional communication within a hospital setting based in the United States. Nine focus groups were conducted including a range of healthcare professions. The focus groups explored practitioners' experiences working on two floors of a newly designed hospital and included questions about the ways in which technology shaped communication with other healthcare professionals. All focus groups were recorded, transcribed, and coded to identify themes. Participant responses focused on the electronic medical record, and while some benefits of the electronic medical record were discussed, participants indicated use of the electronic medical record has resulted in a reduction of in-person communication. Different charting approaches resulted in barriers to communication between specialties and reduced confidence that other practitioners had received one's notes. Limitations in technology-including limited computer availability, documentation complexity, and sluggish sign-in processes-also were identified as barriers to effective and timely communication between practitioners. Given the ways in which technology shapes interprofessional communication, future research should explore how to create standardised electronic medical record use across professions at the optimal level to support communication and patient care.

  12. Accuracy of information on substance use recorded in medical charts of patients with intentional drug overdose.

    Science.gov (United States)

    Tournier, Marie; Molimard, Mathieu; Titier, Karine; Cougnard, Audrey; Bégaud, Bernard; Gbikpi-Benissan, Georges; Verdoux, Hélène

    2007-07-30

    Psychoactive substance use is a risk factor for suicidal behavior and current intoxication increases the likelihood of serious intentional drug overdose (IDO). The objective was to assess the accuracy of information on substance use recorded in medical charts using toxicological assays as a reference in subjects admitted for IDO to an emergency department. Patients (n=1190) consecutively admitted for IDO were included. Information on substance use was recorded in routine practice by the emergency staff and toxicological assays (cannabis, opiate, buprenorphine, amphetamine/ecstasy, cocaine, LSD) were carried out in urine samples collected as part of routine management. The information on substance use was recorded in medical charts for 24.4% of subjects. A third of subjects (27.5%) were positive for toxicological assays. Recorded substance use allowed correct classification of nearly 80% of subjects. However, specificity (88.6%) was better than sensitivity (54.2%). Compared with toxicological assays, medical records allowed identification of only half of the subjects with current substance use. The usefulness of systematic toxicological assays during hospitalization for IDO should be assessed in further studies exploring whether such information allows medical management to be modified and contributes to improving prognosis.

  13. [An intervention program to improve the quality of the medical records in an Internal Medicine Department].

    Science.gov (United States)

    Wikman, A; Safont, P; Merino, J; Martínez Baltanás, A; Matarranz Del Amo, M; López Calleja, E

    2009-09-01

    The medical records are key documents for the patient's diagnosis, treatment and follow-up. Thus, the clinical histories must be made with high technical quality. Although some studies relate the quality of the clinical history with better control of a disease, as far as we know, there are few that evaluate the quality of the medical record itself. This study aims to analyze the quality of the clinical histories of our Internal Medicine Department and then evaluate the improvement achieved. A descriptive and intervention study with a before and after design was conducted. It included 186 medical records elaborated by the physicians of our Internal Medicine Department. A 16-item Likert-like scale was designed for the evaluation. The items were analyzed item by item and a score combining them was elaborated. A baseline analysis and a second analysis 3 months after making several interventions were made. Weak points were detected in the baseline analysis (described) and after the interventions. There was an improvement in almost all the items, this being very significant in the recording of allergies and habits. The global score also improved significantly. CONCLUSION. The study has allowed us to learn our weak points in the elaboration of the medical records. We have improved their quality with the interventions. We estimate that this intervention has also been useful for the training of internal medicine physicians, residents and students.

  14. A Delphi study among internal medicine clinicians to determine which therapeutic information is essential to record in a medical record.

    Science.gov (United States)

    van Unen, Robert J; Tichelaar, Jelle; Nanayakkara, Prabath W B; van Agtmael, Michiel A; Richir, Milan C; de Vries, Theo P G M

    2015-12-01

    Several studies have demonstrated that using a template for recording general and diagnostic information in the medical record (MR) improves the completeness of MR documentation, communication between doctors, and performance of doctors. However, little is known about how therapeutic information should be structured in the MR. The aim of this study was to investigate which specific therapeutic information registrars and consultants in internal medicine consider essential to record in the MR. Therefore, we carried out a 2-round Internet Delphi study. Fifty-nine items were assessed on a 5-point scale; an item was considered important if ≥ 80% of the respondents awarded it a score of 4 or 5. In total, 26 registrars and 30 consultants in internal medicine completed both rounds of the study. Overall, they considered it essential to include information about 11 items in the MR. Subgroup analyses revealed that the registrars considered 8 additional items essential, whereas the consultants considered 1 additional item essential to record. Study findings can be used as a starting point to develop a structured section of the MR for therapeutic information for both paper and electronic MRs. This section should contain at least 11 items considered essential by registrars and clinical consultants in internal medicine.

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

    Science.gov (United States)

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

    2014-08-01

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

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

    Science.gov (United States)

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

    1998-03-01

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

  17. Medical social work practice in child protection in China: A multiple case study in Shanghai hospitals.

    Science.gov (United States)

    Zhao, Fang; Hämäläinen, Juha; Chen, Yu-Ting

    2017-01-24

    With the rapid development of the child welfare system in China over recent years, medical social work has been increasingly involved in providing child protection services in several hospitals in Shanghai. Focusing on five cases in this paper, the exploratory study aims to present a critical overview of current practices and effects of medical social work for child protection, based on a critical analysis of the multidimensional role of social work practitioners engaged in the provision of child protection services as well as potential challenges. Implications and suggestions for future improvements of China's child protection system are also discussed.

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

    Science.gov (United States)

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

    2012-10-01

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

  19. The dispute medical record storage methods and process analysis%纠纷病案封存方式及流程的分析

    Institute of Scientific and Technical Information of China (English)

    赵文岩

    2014-01-01

    Objective To investigate the manner and process of archiving medical records,hospital archive process optimization in order to achieve the law,according to the process to complete medical record complete archive.Methods According to our hospital on medical disputes occurred archived medical records for data collection,to discuss my hospital medical record archiving solutions are reasonable. After reviewing the relevant laws,regulations,documentation,combined with practical knowledge of the Task Force medical record storage,medical record good way discussion archives and processes.Results dispute medical record rate as time goes on increasing year by year,and because of disputes caused by the number of medical records storage also increases,so the dispute archived medical record should attach great importance to improve the way to optimize processes and achieve better services for patients and well protected medical subject. Conclusion "medical institution medical records management regulations" and "Medical Malpractice" did not have a clear medical record storage requirements,medical records storage work so many problems still exist,requiring medical institutions to strengthen the standardization of the management of medical records storage,rationalizing,legalization.%目的:探讨封存病案的方式及流程,以达到依法、按流程封存病案的目的。方法对我院发生的关于医疗纠纷所封存的病案进行资料采集,讨论我院封存病案的方案是否合理。在查阅相关法律、法规,文献资料,结合实际工作中对病案封存的认识,讨论封存病案的最佳方式及流程。结果医疗纠纷率随着时间的推移呈逐年增长趋势,而其造成的封存病案数量也随之增加。对纠纷病案封存要高度重视,改进方式优化流程,从而更好地为患者服务并保护医疗主体。结论《医疗机构病历管理规定》和《医疗事故处理条例》没有对封存病

  20. Implementation of a Big Data Accessing and Processing Platform for Medical Records in Cloud.

    Science.gov (United States)

    Yang, Chao-Tung; Liu, Jung-Chun; Chen, Shuo-Tsung; Lu, Hsin-Wen

    2017-08-18

    Big Data analysis has become a key factor of being innovative and competitive. Along with population growth worldwide and the trend aging of population in developed countries, the rate of the national medical care usage has been increasing. Due to the fact that individual medical data are usually scattered in different institutions and their data formats are varied, to integrate those data that continue increasing is challenging. In order to have scalable load capacity for these data platforms, we must build them in good platform architecture. Some issues must be considered in order to use the cloud computing to quickly integrate big medical data into database for easy analyzing, searching, and filtering big data to obtain valuable information.This work builds a cloud storage system with HBase of Hadoop for storing and analyzing big data of medical records and improves the performance of importing data into database. The data of medical records are stored in HBase database platform for big data analysis. This system performs distributed computing on medical records data processing through Hadoop MapReduce programming, and to provide functions, including keyword search, data filtering, and basic statistics for HBase database. This system uses the Put with the single-threaded method and the CompleteBulkload mechanism to import medical data. From the experimental results, we find that when the file size is less than 300MB, the Put with single-threaded method is used and when the file size is larger than 300MB, the CompleteBulkload mechanism is used to improve the performance of data import into database. This system provides a web interface that allows users to search data, filter out meaningful information through the web, and analyze and convert data in suitable forms that will be helpful for medical staff and institutions.

  1. Use of the electronic medical record for trauma resuscitations: how does this impact documentation completeness?

    Science.gov (United States)

    Bilyeu, Pam; Eastes, Lynn

    2013-01-01

    Although many trauma centers across the country have implemented electronic medical records (EMRs) for inpatient documentation, they have avoided the use of EMR during the fast-paced trauma resuscitations. The objective of this study was to determine whether documenting electronically during trauma resuscitations has resulted in improvement or degradation of the completeness of data recorded. Forty critical data points were evaluated in 100 pre-EMR charts and 100 post-EMR charts. There was improvement in completeness of charting in 25% of the electronic records reviewed and degradation of completeness of charting in 18% of the records, for a net improvement in completeness of charting of 7% in the electronic records reviewed.

  2. Preserving medical correctness, readability and consistency in de-identified health records

    DEFF Research Database (Denmark)

    Pantazos, Kostas; Lauesen, Søren; Lippert, Søren

    2016-01-01

    written in an abbreviated style that cannot be analyzed grammatically. If we replace a word that looks like a name, but isn’t, we degrade readability and medical correctness. If we fail to replace it when we should, we degrade confidentiality. We de-identified an existing Danish electronic health record......A health record database contains structured data fields that identify the patient, such as patient ID, patient name, e-mail and phone number. These data are fairly easy to de-identify, that is, replace with other identifiers. However, these data also occur in fields with doctors’ free-text notes...... database, ending up with 323,122 patient health records. We had to invent many methods for de-identifying potential identifiers in the free-text notes. The de-identified health records should be used with caution for statistical purposes because we removed health records that were so special...

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

    Science.gov (United States)

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

    2011-12-01

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

  4. Medical Secretaries and Electronic Patient Records: Invisible work and its future?

    DEFF Research Database (Denmark)

    Bossen, Claus

    2012-01-01

    SUMMARY: The upgrade plan for the new electronic patient record (EPR) was changed by the ITdepartment a few weeks after taking it into use. It was the first time for the Regional Hospital to implement a comprehensive EPR and unexpectedly medical secretaries, not performance, IT-bugs, or resistanc...

  5. The work practice of medical secretaries and the implementation of electronic health records in Denmark

    DEFF Research Database (Denmark)

    Bertelsen, Pernille; Nøhr, Christian

    2005-01-01

    The introduction of electronic health records will entail substantial organisational changes to the clinical and administrative staff in hospitals. Hospital owners in Denmark have predicted that these changes will render up to half of medical secretaries redundant. The present study however shows...

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

    Science.gov (United States)

    Aldukheil, Maher A.

    2013-01-01

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

  7. Utilizing uncoded consultation notes from electronic medical records for predictive modeling of colorectal cancer

    NARCIS (Netherlands)

    Hoogendoorn, Mark; Szolovits, Peter; Moons, Leon M G; Numans, ME

    2016-01-01

    OBJECTIVE: Machine learning techniques can be used to extract predictive models for diseases from electronic medical records (EMRs). However, the nature of EMRs makes it difficult to apply off-the-shelf machine learning techniques while still exploiting the rich content of the EMRs. In this paper, w

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

    Science.gov (United States)

    Adeyeye, Adebisi

    2015-01-01

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

  9. The Gap between Actual and Mandated Use of an Electronic Medication Record Three Years after Deployment

    DEFF Research Database (Denmark)

    Granlien, Maren Fich; Hertzum, Morten; Gudmundsen, Jette

    2008-01-01

    Three years after the hospitals in one of Denmark's five healthcare regions deployed an electronic medication record (EMR) four of eight main system facilities are used consistently by only 3%-37% of the hospital wards. Furthermore, four of eight mandated work procedures involving the EMR...

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

    Science.gov (United States)

    Huang, Yuan-Han

    2013-01-01

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

  11. Patient electronic medical record – the importance of proper implementation assessment

    Directory of Open Access Journals (Sweden)

    Maria Karlińska

    2014-12-01

    Full Text Available Digital technologies offer the potential to transform health care. Electronic Medical Record (EMR is used to make paperless computerized patient data in order to increase efficiency of hospital systems and reduce chances of human errors. Its level of implementation is usually assessed using an EMR Adoption Model (EMRAM.

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

    Science.gov (United States)

    Riesenmy, Kelly Rouse

    2011-01-01

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

  13. The name of a person under 18 years of age in the medical records

    Directory of Open Access Journals (Sweden)

    Portillo González Armando F

    2014-07-01

    Full Text Available There is often a question of which is the correct way to write in the medical records, the name of people, who have not reached adulthood. We propose several alternatives that allow, within the regulatory framework, solve in a simple way this requirement for information on health.

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

    Science.gov (United States)

    Stevenson, Ian; And Others

    1990-01-01

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

  15. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Science.gov (United States)

    2010-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical records, including the admission history and physical examination, the discharge summary, all physician... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional...

  16. The use of GP electronic medical records for international comparisons on prescription.

    NARCIS (Netherlands)

    Verheij, R.; Dijk, L. van; Pringle, M.; Elliott, C.; Fleming, D.M.

    2007-01-01

    Aims: Much international research on prescription does not take into account the associated diagnoses. Subsequently, large scale international comparisons on what is prescribed for which disease are relatively rare. Routinely collected GP electronic medical records, whose use is well established in

  17. The use of GP electronic medical records for international comparisons on prescription.

    NARCIS (Netherlands)

    Verheij, R.; Dijk, L. van; Pringle, M.; Elliott, C.; Fleming, D.M.

    2007-01-01

    Aims: Much international research on prescription does not take into account the associated diagnoses. Subsequently, large scale international comparisons on what is prescribed for which disease are relatively rare. Routinely collected GP electronic medical records, whose use is well established in

  18. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Condition of participation: Special medical record requirements for psychiatric hospitals. 482.61 Section 482.61 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS OF PARTICIPATION FOR...

  19. 32 CFR 326.11 - Special procedures for disclosure of medical and psychological records.

    Science.gov (United States)

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Special procedures for disclosure of medical and psychological records. 326.11 Section 326.11 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) PRIVACY PROGRAM NATIONAL RECONNAISSANCE OFFICE PRIVACY ACT PROGRAM § 326.11 Special procedures...

  20. 32 CFR 1801.31 - Special procedures for medical and psychological records.

    Science.gov (United States)

    2010-07-01

    ... 32 National Defense 6 2010-07-01 2010-07-01 false Special procedures for medical and psychological records. 1801.31 Section 1801.31 National Defense Other Regulations Relating to National Defense NATIONAL COUNTERINTELLIGENCE CENTER PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters § 1801.31 Special procedures...

  1. 41 CFR 51-9.303-2 - Special requirements for medical/psychological records.

    Science.gov (United States)

    2010-07-01

    ... 41 Public Contracts and Property Management 1 2010-07-01 2010-07-01 true Special requirements for medical/psychological records. 51-9.303-2 Section 51-9.303-2 Public Contracts and Property Management Other Provisions Relating to Public Contracts COMMITTEE FOR PURCHASE FROM PEOPLE WHO ARE BLIND OR SEVERELY DISABLED 9-PRIVACY ACT RULES...

  2. Present status and development trend of hospital medical records management%医院病案管理工作现状及发展趋势探讨

    Institute of Scientific and Technical Information of China (English)

    黄锋; 陈剑铭

    2013-01-01

    The paper analyzed the development and main problems of medical records management in hospitals,and proposed a number of measures based on the ongoing healthcare reform for medical records management in the hospitals.These include targeted management; innovative management model to enhance service; enhanced information security for better protection of patient privacy and hospital's intangible assets; modern management theories and technologies for resolving remaining problems in medical records management; scientific building of medical records quality control system.On such basis,the paper discussed the development trend and strategy of hospital medical records management.%分析了当前医院病案管理发展情况及存在的主要问题,提出现阶段医院病案管理工作应以医改为契机,有针对性地加强管理;创新管理模式,强化服务;加强信息安全管理,保护患者隐私和医院无形资产;用现代管理理念和技术解决病案管理中的历史问题;科学合理地建立病历质量控制体系.在此基础上,对医院病案管理发展趋势及策略进行了探讨.

  3. Study of Hospital Records Registration in Teaching Hospitals of Hamadan University of Medical Sciences in 2009

    Directory of Open Access Journals (Sweden)

    M. Shokouhee Solgi

    2009-07-01

    Full Text Available Introduction & Objectives: Hospital records are representative evidences of medical team activities. In this study, we analyzed hospital records in Hamadan teaching hospitals to find out the problem extent and possible solutions for the problem.Materials & Methods: In a cross-sectional study, hospital records from teaching hospitals were gathered and put in check lists. We used convenient sampling from all departments, so that by referring to hospital achieve, all new discharged cases from different wards were extracted. We used a 16 item check list which targeted some basic questions like: admission order, discharge order, early and final diagnosis and so on. In each case perfect answer was registered in yes or no boxes. Collected data were analyzed by SPSS16 hardware.Results: We achieved the following results after analyzing 457 records from 4 teaching hospitals; there were admission note in 94% of the patients' files. 93% of physicians and residents had signed the orders. 88% of the history sheets were being singed by medical students and/or residents. Differential diagnoses were present in only 75% of cases. Final diagnoses were found in 90% and discharge notes in 84% of the files. 86% of physicians had recorded therapeutic and/or surgical procedures. Paraclinical procedure recordings were present in 83% of the files. Only 63% of residents and/or interns had signed their progress notes. And nursing papers were signed in 99% of records. There was exact counseling information in 83% of the files which needed to be consulted; meanwhile 82% of the consulted files had been signed by physicians. Conclusion: This study shows that, there are important defects in hospital records. It seems that there are multiple factors contributing to the problem, such as overcrowding of the hospitals, careless medical students and the most important factors is insufficient training about the problem.

  4. Utilizing Electronic Health Record Information to Optimize Medication Infusion Devices: A Manual Data Integration Approach.

    Science.gov (United States)

    Chuk, Amanda; Maloney, Robert; Gawron, Joyce; Skinner, Colin

    Health information technology is increasingly utilized within healthcare delivery systems today. Two examples of this type of technology include the capture of patient-specific information within an electronic health record and intravenous medication infusion devices equipped with dose error reduction software known as drug libraries. Automatic integration of these systems, termed intravenous (IV) interoperability, should serve as the goal toward which all healthcare systems work to maximize patient safety. For institutions lacking IV interoperability, we describe a manual approach of querying the electronic health record to incorporate medication administration information with data from infusion device software to optimize drug library settings. This approach serves to maximize utilization of available information to optimize medication safety provided by drug library software.

  5. Design of Electronic Medical Record User Interfaces: A Matrix-Based Method for Improving Usability

    Directory of Open Access Journals (Sweden)

    Kushtrim Kuqi

    2013-01-01

    Full Text Available This study examines a new approach of using the Design Structure Matrix (DSM modeling technique to improve the design of Electronic Medical Record (EMR user interfaces. The usability of an EMR medication dosage calculator used for placing orders in an academic hospital setting was investigated. The proposed method captures and analyzes the interactions between user interface elements of the EMR system and groups elements based on information exchange, spatial adjacency, and similarity to improve screen density and time-on-task. Medication dose adjustment task time was recorded for the existing and new designs using a cognitive simulation model that predicts user performance. We estimate that the design improvement could reduce time-on-task by saving an average of 21 hours of hospital physicians’ time over the course of a month. The study suggests that the application of DSM can improve the usability of an EMR user interface.

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

    Science.gov (United States)

    Rowlands, Stella; Coverdale, Steven; Callen, Joanne

    2016-12-01

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

  7. Radiation protection in medical centers : teletherapy service; Proteccion radiologica en centros hospitalarios : servicio de teleterapia

    Energy Technology Data Exchange (ETDEWEB)

    Resendiz G, G.; Perez P, M.; Figueroa M, E. [Clinica Medica Sur, Servicio de Radioterapia, Puente de Piedra No. 150, Col. Toriello Guerra, Mexico 14050 D. F. (Mexico)

    2008-12-15

    The General Regulation of Radiation Safety, it clearly provides the classification, requirements and obligations of the various figures relating to a radiation protection system, i.e., the occupationally exposed personnel, the radiation safety responsible, the legal representative, the type of installation, etc. For new installations, the shieldings calculation should be contained in the analytical report with due consideration of factors, such as those surrounding the areas classification based on the occupation type, the work load of the equipment and others. The operation license involves requirements such as the Report and the Radiation Safety Handbook, the Emergencies Plan, the establishment of register levels, investigation and intervention, the way it is carried out medical surveillance of the occupationally exposed personnel, and the description of the protection mechanisms and detection instrumentation and radiation measurement. Deserves mention the case when high readings are recorded in the personal dosimeters, which must submit to an interrogation to the employee, you must determine if it is an incorrect reading to the service provider, you must perform a medical exam blood cell count with relevant to the dose determination, may eventually can lead to a cytogenetic study and the determination to do if confirmed an unexpectedly high dose. Moreover, the technology evolution also implies the development of adaptation measures. For example, the Intensity Modulated Radiation Therapy, which is an advanced high-precision radiotherapy that uses X-ray accelerators for computer-controlled radiation doses precisely to a malignant tumor or specific areas within the tumor, taking into account requires regard to equipment, and space and shielding, time and staff hours for treatment, personnel training, materials for making images (such as two-dimensional arrangements of integrated circuits or diodes, films or portal images), the attention given by the engineers of

  8. THE PEN IS MIGHTIER THAN THE SCALPEL: THE CASE FOR ELECTRONIC MEDICAL RECORDS#

    Directory of Open Access Journals (Sweden)

    D. Hartmann

    2012-01-01

    Full Text Available

    ENGLISH ABSTRACT: A case study evaluated how physical medical records are managed and curated at a large tertiary hospital. It was found that the current microfiching technology was outdated, ineffective, and in many cases an impediment to appropriate care. Alternative record-keeping techniques were evaluated. A proposal for a localised electronic medical record (EMR system, disseminated by tablet computer, is presented in this paper. Issues about ethics and access to information are explored, and some of the issues that have affected global implementation are highlighted.

    AFRIKAANSE OPSOMMING: ’n Gevallestudie wat handel oor die bestuur van mediese rekords van ’n tersiêre hospitaal word voorgehou ’n Voorstel word gemaak om die bestaande datastelsel te vervang met ’n elektroniese rekordstelsel. Etiese- en toegangsaangeleenthede word behandel.

  9. The computer-based patient record challenges towards timeless and spaceless medical practice.

    Science.gov (United States)

    Sicotte, C; Denis, J L; Lehoux, P; Champagne, F

    1998-08-01

    Although computerization is increasingly advocated as a means for hospitals to enhance quality of care and control costs, few studies have evaluated its impact on the day-to-day organization of medical work. This study investigated a large Computerized Patient Record (CPR) project ($50 million U.S.) aimed at allowing physicians to work in a completely electronic record environment. The present multiple-case study analyzed the implementation of this project conducted in four hospitals. Our results show the intricate complexity of introducing the CPR in medical work. Profound obstructions to the achievement of a tighter synchronization between the care and information processes were the main problems. The presence of multiple information systems in one (Communication, Decision Support, and Archival record keeping) was overlooked. It introduced several misconceptions in the meaning and codification of clinical information that were then torn apart between information richness to sustain clinical decisions and concision to sustain care coordination.

  10. Pseudonymization in medical research - the generic data protection concept of the TMF

    Directory of Open Access Journals (Sweden)

    Pommerening, Klaus

    2005-12-01

    Full Text Available Using patient data in medical research nets is in conflict with the patients rights on privacy, in particular when data are collected from several sources and stored in long-term registries. The TMF (Telematics Platform for Medical Research Networks developed a "generic" data protection concept that specifies two models for building research data pools. The german data Protection Commissioners agreed with this concept which in the meantime is the basis for concretisations in several research networks.

  11. Parent report and electronic medical record agreement on asthma education provided and children's tobacco smoke exposure.

    Science.gov (United States)

    Harrington, Kathleen F; Haven, Kristen M; Nuño, Velia Leybas; Magruder, Theresa; Bailey, William C; Gerald, Lynn B

    2013-11-01

    To examine the concordance between parent report and electronic medical record documentation of asthma health education provided during a single clinic visit and second-hand tobacco smoke exposure among children with asthma. Parents of children with asthma were recruited from two types of clinics using different electronic medical record systems: asthma-specialty or general pediatric health department clinics. After their child's outpatient visit, parents were interviewed by trained study staff. Interview data were compared to electronic medical records for agreement in five categories of asthma health education and for the child's environmental tobacco smoke exposure. Kappa statistics were used to identify strength of agreement. Chi square and t-tests were used to examine differences between clinic types. Of 255 parents participating in the study 90.6% were African American and 96.1% were female. Agreement was poor across all clinics but was higher within the asthma specialty clinics than the health department clinics for smoke exposure (κ = 0.410 versus 0.205), asthma diagnosis/disease process (κ = 0.213 versus -0.016) and devices reviewed (κ = 0.253 versus -0.089) with parents generally reporting more education provided. For the 203 children with complete medical records, 40.5% did not have any documentation regarding smoking exposure in the home and 85.2% did not have any documentation regarding exposure elsewhere. We found low concordance between the parent's report and the electronic medical record for smoke exposure and asthma education provided. Un- or under-documented smoke exposure and health education have the potential to affect continuity of care for pediatric patients with asthma.

  12. Fundamental Medical and Engineering Investigations on Protective Artificial Respiration

    CERN Document Server

    Klaas, Michael; Schroder, Wolfgang

    2011-01-01

    This volume contains a collection of papers from the research program 'Protective Artificial Respiration (PAR)'. In 2005 the German Research Association DFG launched the research program PAR which is a joint initiative of medicine and fluid mechanics. The main long-term objective of this program is the development of a more protective artificial respiratory system to reduce the physical stress of patients undergoing artificial respiration. To satisfy this goal 11 projects have been defined. In each of these projects scientists from medicine and fluid mechanics do collaborate in several experim

  13. Identifying risk factors for healthcare-associated infections from electronic medical record home address data

    Directory of Open Access Journals (Sweden)

    Rosenman Marc B

    2010-09-01

    Full Text Available Abstract Background Residential address is a common element in patient electronic medical records. Guidelines from the U.S. Centers for Disease Control and Prevention specify that residence in a nursing home, skilled nursing facility, or hospice within a year prior to a positive culture date is among the criteria for differentiating healthcare-acquired from community-acquired methicillin-resistant Staphylococcus aureus (MRSA infections. Residential addresses may be useful for identifying patients residing in healthcare-associated settings, but methods for categorizing residence type based on electronic medical records have not been widely documented. The aim of this study was to develop a process to assist in differentiating healthcare-associated from community-associated MRSA infections by analyzing patient addresses to determine if residence reported at the time of positive culture was associated with a healthcare facility or other institutional location. Results We identified 1,232 of the patients (8.24% of the sample with positive cultures as probable cases of healthcare-associated MRSA based on residential addresses contained in electronic medical records. Combining manual review with linking to institutional address databases improved geocoding rates from 11,870 records (79.37% to 12,549 records (83.91%. Standardization of patient home address through geocoding increased the number of matches to institutional facilities from 545 (3.64% to 1,379 (9.22%. Conclusions Linking patient home address data from electronic medical records to institutional residential databases provides useful information for epidemiologic researchers, infection control practitioners, and clinicians. This information, coupled with other clinical and laboratory data, can be used to inform differentiation of healthcare-acquired from community-acquired infections. The process presented should be extensible with little or no added data costs.

  14. Medical care providers' perspectives on dental information needs in electronic health records.

    Science.gov (United States)

    Acharya, Amit; Shimpi, Neel; Mahnke, Andrea; Mathias, Richard; Ye, Zhan

    2017-05-01

    The authors conducted this study to identify the most relevant patient dental information in a medical-dental integrated electronic health record (iEHR) necessary for medical care providers to inform holistic treatment. The authors collected input from a diverse sample of 65 participants from a large, regional health system representing 13 medical specialties and administrative units. The authors collected feedback from participants through 11 focus group sessions. Two independent reviewers analyzed focus group transcripts to identify major and minor themes. The authors identified 336 of 385 annotations that most medical care providers coded as relevant. Annotations strongly supporting relevancy to clinical practice aligned with 18 major thematic categories, with the top 6 categories being communication, appointments, system design, medications, treatment plan, and dental alerts. Study participants identified dental data of highest relevance to medical care providers and recommended implementation of user-friendly access to dental data in iEHRs as crucial to holistic care delivery. Identification of the patients' dental information most relevant to medical care providers will inform strategies for improving the integration of that information into the medical-dental iEHR. Copyright © 2017 American Dental Association. Published by Elsevier Inc. All rights reserved.

  15. Knowledge and attitudes of nurses in community health centres about electronic medical records

    Directory of Open Access Journals (Sweden)

    Don O'Mahony

    2014-02-01

    Full Text Available Background: Nurses in primary healthcare record data for the monitoring and evaluation of diseases and services. Information and communications technology (ICT can improve quality in healthcare by providing quality medical records. However, worldwide, the majority of health ICT projects have failed. Individual user acceptance is a crucial factor in successful ICT implementation.Objectives: The aim of this study is to explore nurses’ knowledge, attitudes and perceptions regarding ICT so as to inform the future implementation of electronic medical record (EMR systems.Methods: A qualitative design was used. Semi-structured interviews were undertaken with nurses at three community health centres (CHCs in the King Sabata Dalyindyebo Local Municipality. The interview guide was informed by the literature on user acceptance of ICT. Interviews were recorded and analysed using content analysis.Results: Many nurses knew about health ICT and articulated clearly the potential benefits of an EMR such as fewer errors, more complete records, easier reporting and access to information. They thought that an EMR system would solve the challenges they identified with the current paper-based record system, including duplication of data, misfiling, lack of a chronological patient record, excessive time in recording and reduced time for patient care. For personal ICT needs, approximately half used cellphone Internet-based services and computers.Conclusions: In this study, nurses identified many challenges with the current recording methods. They thought that an EMR should be installed at CHCs. Their knowledge about EMR, positive attitudes to ICT and personal use of ICT devices increase the likelihood of successful EMR implementation at CHCs. 

  16. Breaches of health information: are electronic records different from paper records?

    Science.gov (United States)

    Sade, Robert M

    2010-01-01

    Breaches of electronic medical records constitute a type of healthcare error, but should be considered separately from other types of errors because the national focus on the security of electronic data justifies special treatment of medical information breaches. Guidelines for protecting electronic medical records should be applied equally to paper medical records.

  17. General Principles of Radiation Protection in Fields of Diagnostic Medical Exposure

    OpenAIRE

    Do, Kyung Hyun

    2016-01-01

    After the rapid development of medical equipment including CT or PET-CT, radiation doses from medical exposure are now the largest source of man-made radiation exposure. General principles of radiation protection from the hazard of ionizing radiation are summarized as three key words; justification, optimization, and dose limit. Because medical exposure of radiation has unique considerations, diagnostic reference level is generally used as a reference value, instead of dose limits. In Korea, ...

  18. An algorithm to improve diagnostic accuracy in diabetes in computerised problem orientated medical records (POMR compared with an established algorithm developed in episode orientated records (EOMR

    Directory of Open Access Journals (Sweden)

    Simon de Lusignan

    2015-06-01

    Full Text Available An algorithm that detects errors in diagnosis, classification or coding of diabetes in primary care computerised medial record (CMR systems is currently available.  However, this was developed on CMR systems that are “Episode orientated” medical records (EOMR; and don’t force the user to always code a problem or link data to an existing one.  More strictly problem orientated medical record (POMR systems mandate recording a problem and linking consultation data to them.  

  19. Contribution of Electronic Medical Records to the Management of Rare Diseases

    Directory of Open Access Journals (Sweden)

    Dominique Bremond-Gignac

    2015-01-01

    Full Text Available Purpose. Electronic health record systems provide great opportunity to study most diseases. Objective of this study was to determine whether electronic medical records (EMR in ophthalmology contribute to management of rare eye diseases, isolated or in syndromes. Study was designed to identify and collect patients’ data with ophthalmology-specific EMR. Methods. Ophthalmology-specific EMR software (Softalmo software Corilus was used to acquire ophthalmological ocular consultation data from patients with five rare eye diseases. The rare eye diseases and data were selected and collected regarding expertise of eye center. Results. A total of 135,206 outpatient consultations were performed between 2011 and 2014 in our medical center specialized in rare eye diseases. The search software identified 29 congenital aniridia, 6 Axenfeld/Rieger syndrome, 11 BEPS, 3 Nanophthalmos, and 3 Rubinstein-Taybi syndrome. Discussion. EMR provides advantages for medical care. The use of ophthalmology-specific EMR is reliable and can contribute to a comprehensive ocular visual phenotype useful for clinical research. Conclusion. Routinely EMR acquired with specific software dedicated to ophthalmology provides sufficient detail for rare diseases. These software-collected data appear useful for creating patient cohorts and recording ocular examination, avoiding the time-consuming analysis of paper records and investigation, in a University Hospital linked to a National Reference Rare Center Disease.

  20. Interrater reliability: completing the methods description in medical records review studies.

    Science.gov (United States)

    Yawn, Barbara P; Wollan, Peter

    2005-05-15

    In medical records review studies, information on the interrater reliability (IRR) of the data is seldom reported. This study assesses the IRR of data collected for a complex medical records review study. Elements selected for determining IRR included "demographic" data that require copying explicit information (e.g., gender, birth date), "free-text" data that require identifying and copying (e.g., chief complaints and diagnoses), and data that require abstractor judgment in determining what to record (e.g., whether heart disease was considered). Rates of agreement were assessed by the greatest number of answers (one to all n) that were the same. The IRR scores improved over time. At 1 month, the reliability for demographic data elements was very good, for free-text data elements was good, but for data elements requiring abstractor judgment was unacceptable (only 3.4 of six answers agreed, on average). All assessments after 6 months showed very good to excellent IRR. This study demonstrates that IRR can be evaluated and summarized, providing important information to the study investigators and to the consumer for assessing the reliability of the data and therefore the validity of the study results and conclusions. IRR information should be required for all large medical records studies.

  1. Improving quality in an internal medicine residency program through a peer medical record audit.

    Science.gov (United States)

    Asao, Keiko; Mansi, Ishak A; Banks, Daniel

    2009-12-01

    This study examined the effectiveness of a quality improvement project of a limited didactic session, a medical record audit by peers, and casual feedback within a residency program. Residents audited their peers' medical records from the clinic of a university hospital in March, April, August, and September 2007. A 24-item quality-of-care score was developed for five common diagnoses, expressed from 0 to 100, with 100 as complete compliance. Audit scores were compared by month and experience of the resident as an auditor. A total of 469 medical records, audited by 12 residents, for 80 clinic residents, were included. The mean quality-of-care score was 89 (95% CI = 88-91); the scores in March, April, August, and September were 88 (95% CI = 85-91), 94 (95% CI = 90-96), 87 (95% CI = 85-89), and 91 (95% CI = 89-93), respectively. The mean score of 58 records of residents who had experience as auditors was 94 (95% CI = 89-96) compared with 89 (95% CI = 87-90) for those who did not. The score significantly varied (P = .0009) from March to April and from April to August, but it was not significantly associated with experience as an auditor with multivariate analysis. Residents' compliance with the standards of care was generally high. Residents responded to the project well, but their performance dropped after a break in the intervention. Continuation of the audit process may be necessary for a sustained effect on quality.

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

    Science.gov (United States)

    Bian, Lin

    2015-08-01

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

  3. Clinical Holistic Medicine: the “New Medicine”, the Multiparadigmatic Physician, and the Medical Record

    Directory of Open Access Journals (Sweden)

    Søren Ventegodt

    2004-01-01

    Full Text Available The modern physician is often multiparadigmatic as he serves many different types of people in many different existential circumstances. The physician basically often has three, very different sets of technologies or “toolboxes” at his disposal, derived from three different medical paradigms: classical, manual medicine; biomedicine; and holistic or consciousness-oriented medicine. For lack of a better term, we have called the extended medical science — integrating these three different paradigms and their three strands of tools and methods — the “new medicine”. The excellent physician, mastering the “new medicine”, uses the most efficient way to help every patient, giving him or her exactly what is needed under the circumstances. The excellent physician will choose the right paradigm(s for the person, the illness, or the situation, and will use the case record to keep track of all the subjective and objective factors and events involved in the process of healing through time. The case or medical record has the following purposes: A. Reflection: To keep track of facts, to provide an overview, to encourage causal analysis, to support research and learning, and to reveal mistakes easily. B. Communication: To communicate with the patient with a printout of the case record to create trust and help the patient to remember all assignments and exercises. C. Evidence and safety: To provide evidence and safety for the patient or to be used in case of legal questions. D. Self-discipline: To encourage discipline, as a good case record is basically honest, sober, brief, and sticks to the point. It forces the physician to make an effort to be more diligent and careful than a busy day usually allows.The intention of the case or medical record is ethical: to be sure that you, as a physician, give the best possible treatment to your patient. It helps you to reflect deeply, communicate efficiently, provide evidence and safety, and back your self

  4. Clinical genomics, big data, and electronic medical records: reconciling patient rights with research when privacy and science collide

    Science.gov (United States)

    Greely, Henry T.

    2017-01-01

    Abstract Widespread use of medical records for research, without consent, attracts little scrutiny compared to biospecimen research, where concerns about genomic privacy prompted recent federal proposals to mandate consent. This paper explores an important consequence of the proliferation of electronic health records (EHRs) in this permissive atmosphere: with the advent of clinical gene sequencing, EHR-based secondary research poses genetic privacy risks akin to those of biospecimen research, yet regulators still permit researchers to call gene sequence data ‘de-identified’, removing such data from the protection of the federal Privacy Rule and federal human subjects regulations. Medical centers and other providers seeking to offer genomic ‘personalized medicine’ now confront the problem of governing the secondary use of clinical genomic data as privacy risks escalate. We argue that regulators should no longer permit HIPAA-covered entities to treat dense genomic data as de-identified health information. Even with this step, the Privacy Rule would still permit disclosure of clinical genomic data for research, without consent, under a data use agreement, so we also urge that providers give patients specific notice before disclosing clinical genomic data for research, permitting (where possible) some degree of choice and control. To aid providers who offer clinical gene sequencing, we suggest both general approaches and specific actions to reconcile patients’ rights and interests with genomic research. PMID:28852559

  5. Some comments about the medical record Algunos comentarios sobre el expediente clínico

    Directory of Open Access Journals (Sweden)

    Alfredo Darío Espinosa Brito

    2010-12-01

    Full Text Available Some issues are commented about the medical records at present. There are included aspects as: history, importance, how to teach its performance, different functions, types of medical charts, and individual and institutional responsabilities with this document.Se realizan algunos comentarios acerca del expediente clínico en nuestros días. Se incluyen aspectos relacionados con su historia, su importancia, como enseñar a su realización, diferentes funciones que ha adquirido, tipos de formatos, así como responsabilidades individuales e institucionales con este documento.

  6. Exploring medical student decisions regarding attending live lectures and using recorded lectures.

    Science.gov (United States)

    Gupta, Anmol; Saks, Norma Susswein

    2013-09-01

    Student decisions about lecture attendance are based on anticipated effect on learning. Factors involved in decision-making, the use of recorded lectures and their effect on lecture attendance, all warrant investigation. This study was designed to identify factors in student decisions to attend live lectures, ways in which students use recorded lectures, and if their use affects live lecture attendance. A total of 213 first (M1) and second year (M2) medical students completed a survey about lecture attendance, and rated factors related to decisions to attend live lectures and to utilize recorded lectures. Responses were analyzed overall and by class year and gender. M1 attended a higher percentage of live lectures than M2, while both classes used the same percentage of recorded lectures. Females attended more live lectures, and used a smaller percentage of recorded lectures. The lecturer was a key in attendance decisions. Also considered were the subject and availability of other learning materials. Students use recorded lectures as replacement for live lectures and as supplement to them. Lectures, both live and recorded, are important for student learning. Decisions about lecture placement in the curriculum need to be based on course content and lecturer quality.

  7. A Probabilistic Reasoning Method for Predicting the Progression of Clinical Findings from Electronic Medical Records.

    Science.gov (United States)

    Goodwin, Travis; Harabagiu, Sanda M

    2015-01-01

    In this paper, we present a probabilistic reasoning method capable of generating predictions of the progression of clinical findings (CFs) reported in the narrative portion of electronic medical records. This method benefits from a probabilistic knowledge representation made possible by a graphical model. The knowledge encoded in the graphical model considers not only the CFs extracted from the clinical narratives, but also their chronological ordering (CO) made possible by a temporal inference technique described in this paper. Our experiments indicate that the predictions about the progression of CFs achieve high performance given the COs induced from patient records.

  8. Open source tools for standardized privacy protection of medical images

    Science.gov (United States)

    Lien, Chung-Yueh; Onken, Michael; Eichelberg, Marco; Kao, Tsair; Hein, Andreas

    2011-03-01

    In addition to the primary care context, medical images are often useful for research projects and community healthcare networks, so-called "secondary use". Patient privacy becomes an issue in such scenarios since the disclosure of personal health information (PHI) has to be prevented in a sharing environment. In general, most PHIs should be completely removed from the images according to the respective privacy regulations, but some basic and alleviated data is usually required for accurate image interpretation. Our objective is to utilize and enhance these specifications in order to provide reliable software implementations for de- and re-identification of medical images suitable for online and offline delivery. DICOM (Digital Imaging and Communications in Medicine) images are de-identified by replacing PHI-specific information with values still being reasonable for imaging diagnosis and patient indexing. In this paper, this approach is evaluated based on a prototype implementation built on top of the open source framework DCMTK (DICOM Toolkit) utilizing standardized de- and re-identification mechanisms. A set of tools has been developed for DICOM de-identification that meets privacy requirements of an offline and online sharing environment and fully relies on standard-based methods.

  9. A Way to Understand Inpatients Based on the Electronic Medical Records in the Big Data Environment

    Directory of Open Access Journals (Sweden)

    Hongyi Mao

    2017-01-01

    Full Text Available In recent decades, information technology in healthcare, such as Electronic Medical Record (EMR system, is potential to improve service quality and cost efficiency of the hospital. The continuous use of EMR systems has generated a great amount of data. However, hospitals tend to use these data to report their operational efficiency rather than to understand their patients. Base on a dataset of inpatients’ medical records from a Chinese general public hospital, this study applies a configuration analysis from a managerial perspective and explains inpatients management in a different way. Four inpatient configurations (valued patients, managed patients, normal patients, and potential patients are identified by the measure of the length of stay and the total hospital cost. The implications of the finding are discussed.

  10. Development of a clinical information tool for the electronic medical record: a case study.

    Science.gov (United States)

    Epstein, Barbara A; Tannery, Nancy H; Wessel, Charles B; Yarger, Frances; LaDue, John; Fiorillo, Anthony B

    2010-07-01

    What is the process of developing a clinical information tool to be embedded in the electronic health record of a very large and diverse academic medical center? The development took place at the University of Pittsburgh Health Sciences Library System. The clinical information tool developed is a search box with subject tabs to provide quick access to designated full-text information resources. Each subject tab offers a federated search of a different pool of resources. Search results are organized "on the fly" into meaningful categories using clustering technology and are directly accessible from the results page. After more than a year of discussion and planning, a clinical information tool was embedded in the academic medical center's electronic health record. The library successfully developed a clinical information tool, called Clinical-e, for use at the point of care. Future development will refine the tool and evaluate its impact and effectiveness.

  11. A Way to Understand Inpatients Based on the Electronic Medical Records in the Big Data Environment

    Science.gov (United States)

    2017-01-01

    In recent decades, information technology in healthcare, such as Electronic Medical Record (EMR) system, is potential to improve service quality and cost efficiency of the hospital. The continuous use of EMR systems has generated a great amount of data. However, hospitals tend to use these data to report their operational efficiency rather than to understand their patients. Base on a dataset of inpatients' medical records from a Chinese general public hospital, this study applies a configuration analysis from a managerial perspective and explains inpatients management in a different way. Four inpatient configurations (valued patients, managed patients, normal patients, and potential patients) are identified by the measure of the length of stay and the total hospital cost. The implications of the finding are discussed. PMID:28280506

  12. 75 FR 21662 - Access to Employee Exposure and Medical Records; Extension of the Office of Management and Budget...

    Science.gov (United States)

    2010-04-26

    ... Occupational Safety and Health Administration Access to Employee Exposure and Medical Records; Extension of the... collection requirements contained in its Regulation on Access to Employee Exposure and Medical Records (29... OSHA obtain such information with minimum burden upon employers, especially those operating...

  13. T-Helper I: An Electronic Medical Record Supporting the Treatment of AIDS

    OpenAIRE

    Musen, Mark A.; Schreiner, Josef G.; Campbell, Keith E.; Tu, Samson W.; Shortliffe, Edward H; Fagan, Lawrence M.

    1993-01-01

    THERAPY-HELPER (T-HELPER) is an electronic medical-record system developed at Stanford University that is installed at an AIDS clinic in San Jose, California. The system has been developed using an open, distributed architecture. The T-HELPER workstation supports access by physicians and nurses to online progress notes and hypertext descriptions of ongoing clinical trials. Laboratory and patient-registration data are downloaded automatically from existing hospital information systems. Physici...

  14. A Patient-Held Medical Record Integrating Depression Care into Diabetes Care

    OpenAIRE

    Noriko Satoh-Asahara; Hiroto Ito; Tomoyuki Akashi; Hajime Yamakage; Kazuhiko Kotani; Daisuke Nagata; Kazuyuki Nakagome; Mitsuhiko Noda

    2016-01-01

    PURPOSE Depression is frequently observed in people with diabetes. The purpose of this study is to develop a tool for individuals with diabetes and depression to communicate their comorbid conditions to health-care providers. METHOD We searched the Internet to review patient-held medical records (PHRs) of patients with diabetes and examine current levels of integration of diabetes and depression care in Japan. RESULTS Eight sets of PHRs were found for people with diabetes. All PHRs included c...

  15. Product-line administration: a framework for redefining medical record department services.

    Science.gov (United States)

    Postal, S N

    1990-06-01

    Product-line administration is a viable approach for managing medical records services in an environment that demands high quantity and quality service levels. Product-line administration directs medical record department team members to look outside of the department and seek input from the customers it is intended to serve. The feedback received may be alarming at first, as the current state of products usually reveals a true lack of customer input. As the planning, defining, managing, and marketing phases are implemented, the road will not be easy and rewards will be slow to come. Product-line administration does not provide quick fixes, but it does provide long-term problem resolution as products are refined and new products developed to meet customer needs and expectations. In addition to better meeting the needs of the department's external customers, the department's internal customers' needs and expectations will be addressed. The participative management approach will help nurture each team member's creativity. The team members will have the opportunity to reach their full potential while reaping the rewards and benefits of providing products and services that meet the needs and expectations of all department customers. The future of the health care industry promises more changes as the country moves toward some form of prospective payment in the ambulatory setting. Reactive management and the constant struggle to catch up can no longer be accepted as a management approach. It is imperative that the medical record department be viewed as a business with product lines composed of quality products. The planning, defining, managing, and marketing components of product-line administration afford responsiveness to the current situation and the development of quality products that will ensure that medical record departments are prepared for the future.

  16. Rewriting abortion: deploying medical records in jurisdictional negotiation over a forbidden practice in Senegal.

    Science.gov (United States)

    Suh, Siri

    2014-05-01

    Boundary work refers to the strategies deployed by professionals in the arenas of the public, the law and the workplace to define and defend jurisdictional authority. Little attention has been directed to the role of documents in negotiating professional claims. While boundary work over induced abortion has been extensively documented, few studies have examined jurisdictional disputes over the treatment of abortion complications, or post-abortion care (PAC). This study explores how medical providers deploy medical records in boundary work over the treatment of complications of spontaneous and induced abortion in Senegal, where induced abortion is prohibited under any circumstance. Findings are based on an institutional ethnography of Senegal's national PAC program over a period of 13 months between 2010 and 2011. Data collection methods included in-depth interviews with 36 health care professionals, observation of PAC services at three hospitals, a review of abortion records at each hospital, and a case review of illegal abortions prosecuted by the state. Findings show that health providers produce a particular account of the type of abortion treated through a series of practices such as the patient interview and the clinical exam. Providers obscure induced abortion in medical documents in three ways: the use of terminology that does not differentiate between induced and spontaneous abortion in PAC registers, the omission of data on the type of abortion altogether in PAC registers, and reporting the total number but not the type of abortions treated in hospital data transmitted to state health authorities. The obscuration of suspected induced abortion in the record permits providers to circumvent police inquiry at the hospital. PAC has been implemented in approximately 50 countries worldwide. This study demonstrates the need for additional research on how medical professionals negotiate conflicting medical and legal obligations in the daily practice of treating

  17. Rewriting abortion: deploying medical records in jurisdictional negotiation over a forbidden practice in Senegal

    Science.gov (United States)

    Suh, Siri

    2014-01-01

    Boundary work refers to the strategies deployed by professionals in the arenas of the public, the law and the workplace to define and defend jurisdictional authority. Little attention has been directed to the role of documents in negotiating professional claims. While boundary work over induced abortion has been extensively documented, few studies have examined jurisdictional disputes over the treatment of abortion complications, or post-abortion care (PAC). This study explores how medical providers deploy medical records in boundary work over the treatment of complications of spontaneous and induced abortion in Senegal, where induced abortion is prohibited under any circumstance. Findings are based on an institutional ethnography of Senegal’s national PAC program over a period of 13 months between 2010 and 2011. Data collection methods included in-depth interviews with 36 health care professionals, observation of PAC services at three hospitals, a review of abortion records at each hospital, and a case review of illegal abortions prosecuted by the state. Findings show that health providers produce a particular account of the type of abortion treated through a series of practices such as the patient interview and the clinical exam. Providers obscure induced abortion in medical documents in three ways: the use of terminology that does not differentiate between induced and spontaneous abortion in PAC registers, the omission of data on the type of abortion altogether in PAC registers, and reporting the total number but not the type of abortions treated in hospital data transmitted to state health authorities. The obscuration of suspected induced abortion in the record permits providers to circumvent police inquiry at the hospital. PAC has been implemented in nearly 50 countries worldwide. This study demonstrates the need for additional research on how medical professionals negotiate conflicting medical and legal obligations in the daily practice of treating abortion

  18. Constraints on Biological Mechanism from Disease Comorbidity Using Electronic Medical Records and Database of Genetic Variants.

    Directory of Open Access Journals (Sweden)

    Steven C Bagley

    2016-04-01

    Full Text Available Patterns of disease co-occurrence that deviate from statistical independence may represent important constraints on biological mechanism, which sometimes can be explained by shared genetics. In this work we study the relationship between disease co-occurrence and commonly shared genetic architecture of disease. Records of pairs of diseases were combined from two different electronic medical systems (Columbia, Stanford, and compared to a large database of published disease-associated genetic variants (VARIMED; data on 35 disorders were available across all three sources, which include medical records for over 1.2 million patients and variants from over 17,000 publications. Based on the sources in which they appeared, disease pairs were categorized as having predominant clinical, genetic, or both kinds of manifestations. Confounding effects of age on disease incidence were controlled for by only comparing diseases when they fall in the same cluster of similarly shaped incidence patterns. We find that disease pairs that are overrepresented in both electronic medical record systems and in VARIMED come from two main disease classes, autoimmune and neuropsychiatric. We furthermore identify specific genes that are shared within these disease groups.

  19. [Save or destroy? The importance of medical record for former patients and future patients].

    Science.gov (United States)

    van Leeuwen, F E; Schornagel, J H

    2001-03-10

    In 1995, a new privacy law was introduced in the Netherlands. According to this law, medical records should be saved for 10 years, and then destroyed, unless keeping the records for a longer period follows reasonably from the duties of the treating physician (as is the case, for example, when treating patients with a chronic disease). There are serious concerns with regard to the future availability of medical record data for clinical research and patient care after 2005. Evaluation of the late effects of many medical treatments will no longer be possible in the Netherlands. Patient care, particularly genetic counselling, will be also seriously compromised. As a possible solution the profession might name diagnoses and treatments regarding for which, from the point of view of good care, it is necessary for files to be kept for longer than 10 years. For a uniform nationwide policy it would be better if all files, perhaps after sorting by diagnosis and treatment, should be obligatorily kept for much longer than 10 years, preferably for the duration of the life expectancy.

  20. Natural Language Processing Based Instrument for Classification of Free Text Medical Records

    Directory of Open Access Journals (Sweden)

    Manana Khachidze

    2016-01-01

    Full Text Available According to the Ministry of Labor, Health and Social Affairs of Georgia a new health management system has to be introduced in the nearest future. In this context arises the problem of structuring and classifying documents containing all the history of medical services provided. The present work introduces the instrument for classification of medical records based on the Georgian language. It is the first attempt of such classification of the Georgian language based medical records. On the whole 24.855 examination records have been studied. The documents were classified into three main groups (ultrasonography, endoscopy, and X-ray and 13 subgroups using two well-known methods: Support Vector Machine (SVM and K-Nearest Neighbor (KNN. The results obtained demonstrated that both machine learning methods performed successfully, with a little supremacy of SVM. In the process of classification a “shrink” method, based on features selection, was introduced and applied. At the first stage of classification the results of the “shrink” case were better; however, on the second stage of classification into subclasses 23% of all documents could not be linked to only one definite individual subclass (liver or binary system due to common features characterizing these subclasses. The overall results of the study were successful.

  1. What information is provided in transcripts and Medical Student Performance Records from Canadian Medical Schools? A retrospective cohort study

    Directory of Open Access Journals (Sweden)

    Jason A. Robins

    2014-09-01

    Full Text Available Background: Resident selection committees must rely on information provided by medical schools in order to evaluate candidates. However, this information varies between institutions, limiting its value in comparing individuals and fairly assessing their quality. This study investigates what is included in candidates’ documentation, the heterogeneity therein, as well as its objective data. Methods: Samples of recent transcripts and Medical Student Performance Records were anonymised prior to evaluation. Data were then extracted by two independent reviewers blinded to the submitting university, assessing for the presence of pre-selected criteria; disagreement was resolved through consensus. The data were subsequently analysed in multiple subgroups. Results: Inter-rater agreement equalled 92%. Inclusion of important criteria varied by school, ranging from 22.2% inclusion to 70.4%; the mean equalled 47.4%. The frequency of specific criteria was highly variable as well. Only 17.7% of schools provided any basis for comparison of academic performance; the majority detailed only status regarding pass or fail, without any further qualification. Conclusions: Considerable heterogeneity exists in the information provided in official medical school documentation, as well as markedly little objective data. Standardization may be necessary in order to facilitate fair comparison of graduates from different institutions. Implementation of objective data may allow more effective intra- and inter-scholastic comparison.

  2. Automated semantic indexing of imaging reports to support retrieval of medical images in the multimedia electronic medical record.

    Science.gov (United States)

    Lowe, H J; Antipov, I; Hersh, W; Smith, C A; Mailhot, M

    1999-12-01

    This paper describes preliminary work evaluating automated semantic indexing of radiology imaging reports to represent images stored in the Image Engine multimedia medical record system at the University of Pittsburgh Medical Center. The authors used the SAPHIRE indexing system to automatically identify important biomedical concepts within radiology reports and represent these concepts with terms from the 1998 edition of the U.S. National Library of Medicine's Unified Medical Language System (UMLS) Metathesaurus. This automated UMLS indexing was then compared with manual UMLS indexing of the same reports. Human indexing identified appropriate UMLS Metathesaurus descriptors for 81% of the important biomedical concepts contained in the report set. SAPHIRE automatically identified UMLS Metathesaurus descriptors for 64% of the important biomedical concepts contained in the report set. The overall conclusions of this pilot study were that the UMLS metathesaurus provided adequate coverage of the majority of the important concepts contained within the radiology report test set and that SAPHIRE could automatically identify and translate almost two thirds of these concepts into appropriate UMLS descriptors. Further work is required to improve both the recall and precision of this automated concept extraction process.

  3. Development and validation of algorithms for the detection of statin myopathy signals from electronic medical records.

    Science.gov (United States)

    Chan, S L; Tham, M Y; Tan, S H; Loke, C; Foo, Bpq; Fan, Y; Ang, P S; Brunham, L R; Sung, C

    2017-05-01

    The purpose of this study was to develop and validate sensitive algorithms to detect hospitalized statin-induced myopathy (SIM) cases from electronic medical records (EMRs). We developed four algorithms on a training set of 31,211 patient records from a large tertiary hospital. We determined the performance of these algorithms against manually curated records. The best algorithm used a combination of elevated creatine kinase (>4× the upper limit of normal (ULN)), discharge summary, diagnosis, and absence of statin in discharge medications. This algorithm achieved a positive predictive value of 52-71% and a sensitivity of 72-78% on two validation sets of >30,000 records each. Using this algorithm, the incidence of SIM was estimated at 0.18%. This algorithm captured three times more rhabdomyolysis cases than spontaneous reports (95% vs. 30% of manually curated gold standard cases). Our results show the potential power of utilizing data and text mining of EMRs to enhance pharmacovigilance activities. © 2016 American Society for Clinical Pharmacology and Therapeutics.

  4. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED.

    Science.gov (United States)

    Hill, Robert G; Sears, Lynn Marie; Melanson, Scott W

    2013-11-01

    We evaluate physician productivity using electronic medical records in a community hospital emergency department. Physician time usage per hour was observed and tabulated in the categories of direct patient contact, data and order entry, interaction with colleagues, and review of test results and old records. The mean percentage of time spent on data entry was 43% (95% confidence interval, 39%-47%). The mean percentage of time spent in direct contact with patients was 28%. The pooled weighted average time allocations were 44% on data entry, 28% in direct patient care, 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities. Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters. Total mouse clicks approach 4000 during a busy 10-hour shift. Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care. Improved efficiency in data entry would allow emergency physicians to devote more time to patient care, thus increasing hospital revenue. © 2013.

  5. Using a prenatal electronic medical record to improve documentation within an inner-city healthcare network.

    Science.gov (United States)

    Ghartey, Jeny; Lee, Colleen; Weinberger, Elisheva; Nathan, Lisa M; Merkatz, Irwin R; Bernstein, Peter S

    2014-06-01

    To study the impact of a prenatal electronic medical record (EMR) on the adequacy of documentation. The authors reviewed paper prenatal records (historical control arm and contemporaneous control arm), and prenatal EMRs (study arm). A prenatal quality index (PQI) was developed to assess adequacy of documentation; the prenatal record was assigned a score (range, -1 to 2 for each element, maximum score = 30). A PQI raw score and PQI ratio-that controlled for which elements of care were indicated for a patient-were calculated and compared between the study arm versus historical control arm and then the study arm versus contemporaneous control arm. The median PQI raw score was significantly lower in the study arm compared with historical control arm; however, the PQI ratios were similar between these groups. The PQI raw score was similar in both the study arm and contemporaneous control arm; however the PQI ratio was significantly higher in the study arm when compared with the contemporaneous control arm. Implementation of this prenatal EMR did not have a significant impact on completeness of documentation when compared with a standardized paper prenatal record. Adequacy of documentation seems to be related to the type of practice. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

  6. Automated identification of postoperative complications within an electronic medical record using natural language processing.

    Science.gov (United States)

    Murff, Harvey J; FitzHenry, Fern; Matheny, Michael E; Gentry, Nancy; Kotter, Kristen L; Crimin, Kimberly; Dittus, Robert S; Rosen, Amy K; Elkin, Peter L; Brown, Steven H; Speroff, Theodore

    2011-08-24

    Currently most automated methods to identify patient safety occurrences rely on administrative data codes; however, free-text searches of electronic medical records could represent an additional surveillance approach. To evaluate a natural language processing search-approach to identify postoperative surgical complications within a comprehensive electronic medical record. Cross-sectional study involving 2974 patients undergoing inpatient surgical procedures at 6 Veterans Health Administration (VHA) medical centers from 1999 to 2006. Postoperative occurrences of acute renal failure requiring dialysis, deep vein thrombosis, pulmonary embolism, sepsis, pneumonia, or myocardial infarction identified through medical record review as part of the VA Surgical Quality Improvement Program. We determined the sensitivity and specificity of the natural language processing approach to identify these complications and compared its performance with patient safety indicators that use discharge coding information. The proportion of postoperative events for each sample was 2% (39 of 1924) for acute renal failure requiring dialysis, 0.7% (18 of 2327) for pulmonary embolism, 1% (29 of 2327) for deep vein thrombosis, 7% (61 of 866) for sepsis, 16% (222 of 1405) for pneumonia, and 2% (35 of 1822) for myocardial infarction. Natural language processing correctly identified 82% (95% confidence interval [CI], 67%-91%) of acute renal failure cases compared with 38% (95% CI, 25%-54%) for patient safety indicators. Similar results were obtained for venous thromboembolism (59%, 95% CI, 44%-72% vs 46%, 95% CI, 32%-60%), pneumonia (64%, 95% CI, 58%-70% vs 5%, 95% CI, 3%-9%), sepsis (89%, 95% CI, 78%-94% vs 34%, 95% CI, 24%-47%), and postoperative myocardial infarction (91%, 95% CI, 78%-97%) vs 89%, 95% CI, 74%-96%). Both natural language processing and patient safety indicators were highly specific for these diagnoses. Among patients undergoing inpatient surgical procedures at VA medical centers

  7. 述病案是法律文书或法律文件的谬误%The Discussion of Fallacy of Medical Records are Legal Records or Legal Documents

    Institute of Scientific and Technical Information of China (English)

    裴完花; 何艳红; 赵晓娟

    2013-01-01

      文章阐述了法律文书与法律文件的含义,批驳了有些文章中经常把病案称作是法律文件,将医师书写的病历记录和护士所做的护理记录、医嘱记录说成是法律文书,是一种极大谬误,是一些人员对病案认识上的误差。强调了病历是指医务人员在医疗活动过程中形成的文字、符号、图表、影像、切片等资料的总和,是医务人员在为患者施治疾病过程中为了疾病观察、连续医疗的依据。通过所列举的有关案例,提示医务人员只有遵守客观、真实、准确、及时、完整、规范的书写病历,才能有效维护医疗工作的合法权益。%This paper expound the meaning of the legal records and legal documents ,refute the point of “The medical record is called legal documents”in some articles .They regard medical records and nursing record ,the doctor’s advice record as legal docu-ments .This point is a great fallacy .This article emphasizes the medical records is the sum total of words ,symbols ,graphics ,im-ages ,slice in the process of medical treatment activity ,and is the basis of disease observation ,continuous medical in the process of medical treatment activity .Through listing the relevant cases ,medical staff should write records objectively ,truly ,accurately ,time-ly ,completely and standardly to effectively protect the lawful rights and interests of the medical work .

  8. The Data Protection (Amendment) Act, 2003: the Data Protection Directive and its implications for medical research in Ireland.

    Science.gov (United States)

    Sheikh, Asim A

    2005-12-01

    Directive 95/46/EC on the Protection of Individuals with regard to the Processing of Personal Data and on the Free Movement of Such Data has been transposed into national law and is now the Data Protection (Amendment) Act, 2003. The Directive and the transposing Act provide for new obligations to those processing data. The new obligation of primary concern is the necessity to obtain consent prior to the processing of data (Article 7, Directive 95/46/EC). This has caused much concern especially in relation to 'secondary data' or 'archived data'. There exist, what seem to be in the minds of the medical research community, two competing interests: (i) that of the need to obtain consent prior to processing data and (ii) the need to protect and foster medical research. At the same time as the introduction of the Act, other prior legislation, i.e. the Freedom of Information Act, 1997-2003, has encouraged candour within the doctor-patient relationship and the High Court in Ireland, in the case of Geoghegan v. Harris, has promulgated the 'reasonable-patient test' as being the correct law in relation to the disclosure of risks to patients. The court stated that doctors have a duty to disclose all material risks to patients. The case demonstrates an example of a move toward a more open medical relationship. An example of this rationale was also recently seen in the United Kingdom in the House of Lords decision in Chester v. Afshar. Within the medical research community in Ireland, the need to respect the autonomy of patients and research participants by providing information to such parties has also been observed (Sheikh A. A., 2000 and Irish Council for Bioethics, 2005). Disquiet has been expressed in Ireland and other jurisdictions by the medical research communities in relation to the exact working and meaning of the Directive and therefore the transposing Acts (Strobl et al). This may be due to the fact that, as observed by Beyleveld "The Directive makes no specific

  9. Radiation protection in medical and biomedical research; Proteccion radiologica en la investigacion medica y biomedica

    Energy Technology Data Exchange (ETDEWEB)

    Fuente Puch, A.E. de la, E-mail: andres@orasen.co.cuES [Centro Nacional de Seguridad Nuclear, La Habana (Cuba)

    2013-11-01

    The human exposure to ionizing radiation in the context of medical and biomedical research raises specific ethical challenges whose resolution approaches should be based on scientific, legal and procedural matters. Joint Resolution MINSAP CITMA-Regulation 'Basic Standards of Radiation Safety' of 30 November 2001 (hereafter NBS) provides for the first time in Cuba legislation specifically designed to protect patients and healthy people who participate in research programs medical and biomedical and exposed to radiation. The objective of this paper is to demonstrate the need to develop specific requirements for radiation protection in medical and biomedical research, as well as to identify all the institutions involved in this in order to establish the necessary cooperation to ensure the protection of persons participating in the investigation.

  10. Automatic prediction of rheumatoid arthritis disease activity from the electronic medical records.

    Directory of Open Access Journals (Sweden)

    Chen Lin

    Full Text Available OBJECTIVE: We aimed to mine the data in the Electronic Medical Record to automatically discover patients' Rheumatoid Arthritis disease activity at discrete rheumatology clinic visits. We cast the problem as a document classification task where the feature space includes concepts from the clinical narrative and lab values as stored in the Electronic Medical Record. MATERIALS AND METHODS: The Training Set consisted of 2792 clinical notes and associated lab values. Test Set 1 included 1749 clinical notes and associated lab values. Test Set 2 included 344 clinical notes for which there were no associated lab values. The Apache clinical Text Analysis and Knowledge Extraction System was used to analyze the text and transform it into informative features to be combined with relevant lab values. RESULTS: Experiments over a range of machine learning algorithms and features were conducted. The best performing combination was linear kernel Support Vector Machines with Unified Medical Language System Concept Unique Identifier features with feature selection and lab values. The Area Under the Receiver Operating Characteristic Curve (AUC is 0.831 (σ = 0.0317, statistically significant as compared to two baselines (AUC = 0.758, σ = 0.0291. Algorithms demonstrated superior performance on cases clinically defined as extreme categories of disease activity (Remission and High compared to those defined as intermediate categories (Moderate and Low and included laboratory data on inflammatory markers. CONCLUSION: Automatic Rheumatoid Arthritis disease activity discovery from Electronic Medical Record data is a learnable task approximating human performance. As a result, this approach might have several research applications, such as the identification of patients for genome-wide pharmacogenetic studies that require large sample sizes with precise definitions of disease activity and response to therapies.

  11. MODERNIZATION OF RUSSIAN HEALT PROTECTION SYSTEM SOLVES THE PROBLEM OF RENDERING QUALITY MEDICAL AID TO POPULATION

    Directory of Open Access Journals (Sweden)

    V. A. Alexeev

    2011-01-01

    Full Text Available Last two dozen years, permanent growth of death rate and decrease birth rate take place in Russia. To great extent, this is owing to inadequate health protection system. The practice of personal payments for medical services in amounts unattainable for overwhelming majority of thepopulation grows. RF President’s Administration sets an example: cardiologist’s advice in their clinics costs 40 times more that according to obligatory medical insurance rates. 84% of the country citizens do not approve this approach and consider it socially unjust. An important national project aimed at modernization of the health protection system started in 2011. Non-private medical establishments are to be equipped with up-to-date equipment, modern information systems and medical service standards based on CRM system adopted in developed countries; salaries of health personnel are to be increased.

  12. RADIATION ACCIDENTS: EXPERIENCE OF MEDICAL PROTECTION AND MODERN STRATEGY OF PHARMACOLOGICAL MAINTENANCE

    Directory of Open Access Journals (Sweden)

    A. N. Grebenyuk

    2012-01-01

    Full Text Available Experience of medical protection at radiation accidents is analyzed. It is shown, that medicines that have been in the arsenal of medical service during the liquidation of consequences of the Chernobyl nuclear power plant accident satisfied their predestination in a whole and were rather effective for radiation protection. The modern strategy of pharmacological maintenance based on use of means and methods, allowing to keeping a life, health and professional serviceability of people in conditions of amazing action of a complex of factors of radiation accidents, is submitted.

  13. Conflicts of interest for medical publishers and editors: protecting the integrity of scientific scholarship.

    Science.gov (United States)

    Desai, Sapan S; Shortell, Cynthia K

    2011-09-01

    Competition of interest may exist at all levels in the medical publication process. Ensuring the integrity of scientific scholarship involves protecting editorial independence, promoting the use of scientific arbitration boards, promoting transparency throughout all stages of publication, and protecting the relationship between the publisher and its editors through an effective legal framework. It is incumbent upon the publisher, editors, authors, and readers to ensure that the highest standards of scientific scholarship are upheld. Doing so will help reduce fraud and misrepresentation in medical research and increase the trustworthiness of landmark findings in science.

  14. Evaluation of Electronic Medical Record (EMR at large urban primary care sexual health centre.

    Directory of Open Access Journals (Sweden)

    Christopher K Fairley

    Full Text Available OBJECTIVE: Despite substantial investment in Electronic Medical Record (EMR systems there has been little research to evaluate them. Our aim was to evaluate changes in efficiency and quality of services after the introduction of a purpose built EMR system, and to assess its acceptability by the doctors, nurses and patients using it. METHODS: We compared a nine month period before and after the introduction of an EMR system in a large sexual health service, audited a sample of records in both periods and undertook anonymous surveys of both staff and patients. RESULTS: There were 9,752 doctor consultations (in 5,512 consulting hours in the Paper Medical Record (PMR period and 9,145 doctor consultations (in 5,176 consulting hours in the EMR period eligible for inclusion in the analysis. There were 5% more consultations per hour seen by doctors in the EMR period compared to the PMR period (rate ratio = 1.05; 95% confidence interval, 1.02, 1.08 after adjusting for type of consultation. The qualitative evaluation of 300 records for each period showed no difference in quality (P>0.17. A survey of clinicians demonstrated that doctors and nurses preferred the EMR system (P<0.01 and a patient survey in each period showed no difference in satisfaction of their care (97% for PMR, 95% for EMR, P = 0.61. CONCLUSION: The introduction of an integrated EMR improved efficiency while maintaining the quality of the patient record. The EMR was popular with staff and was not associated with a decline in patient satisfaction in the clinical care provided.

  15. Towards iconic language for patient records, drug monographs, guidelines and medical search engines.

    Science.gov (United States)

    Lamy, Jean-Baptiste; Duclos, Catherine; Hamek, Saliha; Beuscart-Zéphir, Marie-Catherine; Kerdelhué, Gaetan; Darmoni, Stefan; Favre, Madeleine; Falcoff, Hector; Simon, Christian; Pereira, Suzanne; Serrot, Elisabeth; Mitouard, Thierry; Hardouin, Etienne; Kergosien, Yannick; Venot, Alain

    2010-01-01

    Practicing physicians have limited time for consulting medical knowledge and records. We have previously shown that using icons instead of text to present drug monographs may allow contraindications and adverse effects to be identified more rapidly and more accurately. These findings were based on the use of an iconic language designed for drug knowledge, providing icons for many medical concepts, including diseases, antecedents, drug classes and tests. In this paper, we describe a new project aimed at extending this iconic language, and exploring the possible applications of these icons in medicine. Based on evaluators' comments, focus groups of physicians and opinions of academic, industrial and associative partners, we propose iconic applications related to patient records, for example summarizing patient conditions, searching for specific clinical documents and helping to code structured data. Other applications involve the presentation of clinical practice guidelines and improving the interface of medical search engines. These new applications could use the same iconic language that was designed for drug knowledge, with a few additional items that respect the logic of the language.

  16. Implementing and Integrating a Clinically-Driven Electronic Medical Record (EMR for Radiation Oncology in a Large Medical Enterprise

    Directory of Open Access Journals (Sweden)

    John Paxton Kirkpatrick

    2013-04-01

    Full Text Available Purpose/Objective: While our department is heavily invested in computer-based treatment planning, we historically relied on paper-based charts for management of Radiation Oncology patients. In early 2009, we initiated the process of conversion to an electronic medical record (EMR eliminating the need for paper charts. Key goals included the ability to readily access information wherever and whenever needed, without compromising safety, treatment quality, confidentiality or productivity.Methodology: In February, 2009, we formed a multi-disciplinary team of Radiation Oncology physicians, nurses, therapists, administrators, physicists/dosimetrists, and information technology (IT specialists, along with staff from the Duke Health System IT department. The team identified all existing processes and associated information/reports, established the framework for the EMR system and generated, tested and implemented specific EMR processes.Results: Two broad classes of information were identified: information which must be readily accessed by anyone in the health system versus that used solely within the Radiation Oncology department. Examples of the former are consultation reports, weekly treatment check notes and treatment summaries; the latter includes treatment plans, daily therapy records and quality assurance reports. To manage the former, we utilized the enterprise-wide system , which required an intensive effort to design and implement procedures to export information from Radiation Oncology into that system. To manage "Radiation Oncology" data, we used our existing system (ARIA, Varian Medical Systems. The ability to access both systems simultaneously from a single workstation (WS was essential, requiring new WS and modified software. As of January, 2010, all new treatments were managed solely with an EMR. We find that an EMR makes information more widely accessible and does not compromise patient safety, treatment quality or confidentiality

  17. Mining free-text medical records for companion animal enteric syndrome surveillance.

    Science.gov (United States)

    Anholt, R M; Berezowski, J; Jamal, I; Ribble, C; Stephen, C

    2014-03-01

    Large amounts of animal health care data are present in veterinary electronic medical records (EMR) and they present an opportunity for companion animal disease surveillance. Veterinary patient records are largely in free-text without clinical coding or fixed vocabulary. Text-mining, a computer and information technology application, is needed to identify cases of interest and to add structure to the otherwise unstructured data. In this study EMR's were extracted from veterinary management programs of 12 participating veterinary practices and stored in a data warehouse. Using commercially available text-mining software (WordStat™), we developed a categorization dictionary that could be used to automatically classify and extract enteric syndrome cases from the warehoused electronic medical records. The diagnostic accuracy of the text-miner for retrieving cases of enteric syndrome was measured against human reviewers who independently categorized a random sample of 2500 cases as enteric syndrome positive or negative. Compared to the reviewers, the text-miner retrieved cases with enteric signs with a sensitivity of 87.6% (95%CI, 80.4-92.9%) and a specificity of 99.3% (95%CI, 98.9-99.6%). Automatic and accurate detection of enteric syndrome cases provides an opportunity for community surveillance of enteric pathogens in companion animals.

  18. Staff empowerment: a medical record department's preliminary experiences with continuous quality improvement.

    Science.gov (United States)

    Markon, E

    1992-11-01

    After observing the results of continuous quality improvement, no one would argue against its value in the workplace. However, learning to apply the concepts requires change on everyone's part, and the challenge lies in effecting this change. Not everyone will want to work in this type of environment and, if the organization is truly committed to continuous quality improvement, those individuals may have to make hard decisions as to whether the organization is the right place for them to work. Certain skills are required for staff empowerment to be successful, and training in these skills is essential. The medical record department staff learned early in this process that, although the group possessed job skills, interaction and team skills were lacking. The Development Dimensions International program helped the managers and staff identify the weaknesses of the group and provided educational tools for improvement. The changes often are so subtle, the group does not realize anything has changed. It was not until recently, when the medical record department staff was requested by administration to identify department quality improvement projects, that the group looked back at where the process started and realized how different things are today from three years ago--now staff members lead team meetings, work-groups are redesigning their job processes, and teams update the rest of the department staff on its progress at department meetings. Everyone expressed a sense of pride and accomplishment that the group had indeed responded to the challenge. The experiences of the medical record department thus far clearly support empowerment of employees.(ABSTRACT TRUNCATED AT 250 WORDS)

  19. Risk factor detection for heart disease by applying text analytics in electronic medical records.

    Science.gov (United States)

    Torii, Manabu; Fan, Jung-Wei; Yang, Wei-Li; Lee, Theodore; Wiley, Matthew T; Zisook, Daniel S; Huang, Yang

    2015-12-01

    In the United States, about 600,000 people die of heart disease every year. The annual cost of care services, medications, and lost productivity reportedly exceeds 108.9 billion dollars. Effective disease risk assessment is critical to prevention, care, and treatment planning. Recent advancements in text analytics have opened up new possibilities of using the rich information in electronic medical records (EMRs) to identify relevant risk factors. The 2014 i2b2/UTHealth Challenge brought together researchers and practitioners of clinical natural language processing (NLP) to tackle the identification of heart disease risk factors reported in EMRs. We participated in this track and developed an NLP system by leveraging existing tools and resources, both public and proprietary. Our system was a hybrid of several machine-learning and rule-based components. The system achieved an overall F1 score of 0.9185, with a recall of 0.9409 and a precision of 0.8972.

  20. Measuring the success of electronic medical record implementation using electronic and survey data.

    Science.gov (United States)

    Keshavjee, K; Troyan, S; Holbrook, A M; VanderMolen, D

    2001-01-01

    Computerization of physician practices is increasing. Stakeholders are demanding demonstrated value for their Electronic Medical Record (EMR) implementations. We developed survey tools to measure medical office processes, including administrative and physician tasks pre- and post-EMR implementation. We included variables that were expected to improve with EMR implementation and those that were not expected to improve, as controls. We measured the same processes pre-EMR, at six months and 18 months post-EMR. Time required for most administrative tasks decreased within six months of EMR implementation. Staff time spent on charting increased with time, in keeping with our anecdotal observations that nurses were given more responsibility for charting in many offices. Physician time to chart increased initially by 50%, but went down to original levels by 18 months. However, this may be due to the drop-out of those physicians who had a difficult time charting electronically.

  1. Towards Standardized Patient Data Exchange: Integrating a FHIR Based API for the Open Medical Record System.

    Science.gov (United States)

    Kasthurirathne, Suranga N; Mamlin, Burke; Grieve, Grahame; Biondich, Paul

    2015-01-01

    Interoperability is essential to address limitations caused by the ad hoc implementation of clinical information systems and the distributed nature of modern medical care. The HL7 V2 and V3 standards have played a significant role in ensuring interoperability for healthcare. FHIR is a next generation standard created to address fundamental limitations in HL7 V2 and V3. FHIR is particularly relevant to OpenMRS, an Open Source Medical Record System widely used across emerging economies. FHIR has the potential to allow OpenMRS to move away from a bespoke, application specific API to a standards based API. We describe efforts to design and implement a FHIR based API for the OpenMRS platform. Lessons learned from this effort were used to define long term plans to transition from the legacy OpenMRS API to a FHIR based API that greatly reduces the learning curve for developers and helps enhance adhernce to standards.

  2. Radiation protection in medical applications; La proteccion radiologica en las aplicaciones medicas

    Energy Technology Data Exchange (ETDEWEB)

    Maldonado M, H. [Sociedad Mexicana de Seguridad Radiologica A. C., Mexico D. F. (Mexico)

    2008-12-15

    The justification of the practices is the fundamental principle on which rests the peaceful use of ionizing radiations. They actually contain as aspirations to improve the quality of people's lives, contributing to sustainable development through environmental protection, so that the sources security and the individuals protection will be conditions which are not and should can not be operated. For medical applications is a highly illustrative example of this, since both for the diagnosis and therapy, the goal is to achieve what is sought for the white tissue, secured the least possible damage to the neighboring tissues so that in turn reduce the negative effects for the patient. As a basis for achieving the above, it is essential to have qualified personnel in all areas incidents, for example users, workers, officials and staff members. There are a variety of specialists in the field of medical applications as, nuclear chemistry, nuclear engineering, radiation protection, medical physics, radiation physics and others. Among the human resource in the country must make up the majority are medical radiologists, highlighting gaps in the number of radiotherapy and nuclear medicine but specially in the medical physics, who is in some way from a special viewpoint of the formal school, new to the country. This is true for the number of facilities which are in the country. The radiation protection responsibilities in medical applications focus primarily on two figures: the radiology safety manager, who is primarily dedicated to the protection of occupationally exposed personnel and the public, and the medical physicist whose functions are geared towards the radiological protection of the patient. The principal legislation in the medical applications area has been enacted and is monitored by the Health Secretary and National Commission on Nuclear Safety and Safeguards, entities that have reached agreements to avoid overlap and over-regulation. Medical applications in

  3. 3DLC: A Comprehensive Model for Personal Health Records Supporting New Types of Medical Applications

    Directory of Open Access Journals (Sweden)

    Axel Helmer

    2011-01-01

    Full Text Available Motivated by the demographic change, many new medical applications are installed in the user's home environment. These applications make use of ambient sensors, enabling new forms of medical care. Personal Health Records (PHRs are an instrument for the storage, presentation and communication of health related data provided by these applications. But there are still open issues regarding the cooperation between PHRs and the new applications. On the basis of two medical application scenarios, we developed a new model which defines the appropriate level of abstraction of data generated by medical applications to be stored inside the PHR. The model also determines which part of these data is relevant for the clinical decision making process, and how these data should be communicated to physicians. This paper describes the 3DLC model, which uses three dimensions (clinical decision, frequency and context dependence to determine the type of the data. We further introduce a prototype PHR system that is able to fulfil the requirements of our scenarios.

  4. Electronic medical records (EMRs), epidemiology, and epistemology: reflections on EMRs and future pediatric clinical research.

    Science.gov (United States)

    Wasserman, Richard C

    2011-01-01

    Electronic medical records (EMRs) are increasingly common in pediatric patient care. EMR data represent a relatively novel and rich resource for clinical research. The fact, however, that pediatric EMR data are collected for the purposes of clinical documentation and billing rather than research creates obstacles to their use in scientific investigation. Particular issues include accuracy, completeness, comparability between settings, ease of extraction, and context of recording. Although these problems can be addressed through standard strategies for dealing with partially accurate and incomplete data, a longer-term solution will involve work with pediatric clinicians to improve data quality. As research becomes one of the explicit purposes for which pediatricians collect EMR data, the pediatric clinician will play a central role in future pediatric clinical research.

  5. Three years experience with the implementation of a networked electronic medical record in Haiti.

    Science.gov (United States)

    Lober, William B; Quiles, Christina; Wagner, Steve; Cassagnol, Rachelle; Lamothes, Roges; Alexis, Don Rock Pierre; Joseph, Patrice; Sutton, Perri; Puttkammer, Nancy; Kitahata, Mari M

    2008-11-06

    Since 2005 we have been developing and implementing an electronic medical record (EMR) that supports both individual and population health care of HIV-infected patients in Haiti. Unreliable electrical power and network infrastructure, cultural differences, variable levels of experience and computer literacy, and the geographic dispersion of the team remain challenges, but the system is now implemented in about 40 sites nationwide providing antiretroviral therapy, and includes records for about 18,600 patients. The need to support country-wide monitoring and evaluation drove early architectural decisions to support linking systems under conditions of network uncertainty. We have found surprising end user acceptance of the system, with the adoption of interactive EMR usage exceeding our expectations and timeline.

  6. Hospital Bed Type, the Electronic Medical Record, and Safe Bed Elevation in the Intensive Care Setting.

    Science.gov (United States)

    Fitch, Zachary W; Duquaine, Damon; Ohkuma, Rika; Schneider, Eric B; Whitman, Glenn J R

    2016-01-01

    In mechanically ventilated patients, head of bed (HOB) elevation above 30° decreases the risk of ventilator-associated pneumonia. The research team studied (a) compliance with proper HOB elevation in their cardiac surgical intensive care unit, (b) the accuracy of HOB angles recorded in the electronic medical record (EMR), and (c) the effect of bed type on (a) and (b). Nurses were polled to discover how HOB angles were measured in practice. HOB angles were compliant in 80% of observations. Compliance was more frequent in beds with side-of-bed angle indicators (SBI) than beds with under-bed angle indicators (UBI; 88% vs 77%, P = .04). Charting in the EMR was accurate in 50% of SBI bed observations but only 20% of UBI bed observations (P bed type. Bedside indicators are underutilized. © The Author(s) 2014.

  7. Risk mitigation of shared electronic records system in campus institutions: medical social work practice in singapore.

    Science.gov (United States)

    Ow Yong, Lai Meng; Tan, Amanda Wei Li; Loo, Cecilia Lay Keng; Lim, Esther Li Ping

    2014-10-01

    In 2013, the Singapore General Hospital (SGH) Campus initiated a shared electronic system where patient records and documentations were standardized and shared across institutions within the Campus. The project was initiated to enhance quality of health care, improve accessibility, and ensure integrated (as opposed to fragmented) care for best outcomes in our patients. In mitigating the risks of ICT, it was found that familiarity with guiding ethical principles, and ensuring adherence to regulatory and technical competencies in medical social work were important. The need to negotiate and maneuver in a large environment within the Campus to ensure proactive integrative process helped.

  8. Using the NASA Task Load Index to Assess Workload in Electronic Medical Records.

    Science.gov (United States)

    Hudson, Darren; Kushniruk, Andre W; Borycki, Elizabeth M

    2015-01-01

    Electronic medical records (EMRs) has been expected to decrease health professional workload. The NASA Task Load Index has become an important tool for assessing workload in many domains. However, its application in assessing the impact of an EMR on nurse's workload has remained to be explored. In this paper we report the results of a study of workload and we explore the utility of applying the NASA Task Load Index to assess impact of an EMR at the end of its lifecycle on nurses' workload. It was found that mental and temporal demands were the most responsible for the workload. Further work along these lines is recommended.

  9. Task and error analysis balancing benefits over business of electronic medical records.

    Science.gov (United States)

    Carstens, Deborah Sater; Rodriguez, Walter; Wood, Michael B

    2014-01-01

    Task and error analysis research was performed to identify: a) the process for healthcare organisations in managing healthcare for patients with mental illness or substance abuse; b) how the process can be enhanced and; c) if electronic medical records (EMRs) have a role in this process from a business and safety perspective. The research question is if EMRs have a role in enhancing the healthcare for patients with mental illness or substance abuse. A discussion on the business of EMRs is addressed to understand the balancing act between the safety and business aspects of an EMR.

  10. DICOM image integration into an electronic medical record using thin viewing clients

    Science.gov (United States)

    Stewart, Brent K.; Langer, Steven G.; Taira, Ricky K.

    1998-07-01

    Purpose -- To integrate radiological DICOM images into our currently existing web-browsable Electronic Medical Record (MINDscape). Over the last five years the University of Washington has created a clinical data repository combining in a distributed relational database information from multiple departmental databases (MIND). A text-based view of this data called the Mini Medical Record (MMR) has been available for three years. MINDscape, unlike the text based MMR, provides a platform independent, web browser view of the MIND dataset that can easily be linked to other information resources on the network. We have now added the integration of radiological images into MINDscape through a DICOM webserver. Methods/New Work -- we have integrated a commercial webserver that acts as a DICOM Storage Class Provider to our, computed radiography (CR), computed tomography (CT), digital fluoroscopy (DF), magnetic resonance (MR) and ultrasound (US) scanning devices. These images can be accessed through CGI queries or by linking the image server database using ODBC or SQL gateways. This allows the use of dynamic HTML links to the images on the DICOM webserver from MINDscape, so that the radiology reports already resident in the MIND repository can be married with the associated images through the unique examination accession number generated by our Radiology Information System (RIS). The web browser plug-in used provides a wavelet decompression engine (up to 16-bits per pixel) and performs the following image manipulation functions: window/level, flip, invert, sort, rotate, zoom, cine-loop and save as JPEG. Results -- Radiological DICOM image sets (CR, CT, MR and US) are displayed with associated exam reports for referring physician and clinicians anywhere within the widespread academic medical center on PCs, Macs, X-terminals and Unix computers. This system is also being used for home teleradiology application. Conclusion -- Radiological DICOM images can be made available

  11. Sequential planning of flood protection infrastructure under limited historic flood record and climate change uncertainty

    Science.gov (United States)

    Dittes, Beatrice; Špačková, Olga; Straub, Daniel

    2017-04-01

    Flood protection is often designed to safeguard people and property following regulations and standards, which specify a target design flood protection level, such as the 100-year flood level prescribed in Germany (DWA, 2011). In practice, the magnitude of such an event is only known within a range of uncertainty, which is caused by limited historic records and uncertain climate change impacts, among other factors (Hall & Solomatine, 2008). As more observations and improved climate projections become available in the future, the design flood estimate changes and the capacity of the flood protection may be deemed insufficient at a future point in time. This problem can be mitigated by the implementation of flexible flood protection systems (that can easily be adjusted in the future) and/or by adding an additional reserve to the flood protection, i.e. by applying a safety factor to the design. But how high should such a safety factor be? And how much should the decision maker be willing to pay to make the system flexible, i.e. what is the Value of Flexibility (Špačková & Straub, 2017)? We propose a decision model that identifies cost-optimal decisions on flood protection capacity in the face of uncertainty (Dittes et al. 2017). It considers sequential adjustments of the protection system during its lifetime, taking into account its flexibility. The proposed framework is based on pre-posterior Bayesian decision analysis, using Decision Trees and Markov Decision Processes, and is fully quantitative. It can include a wide range of uncertainty components such as uncertainty associated with limited historic record or uncertain climate or socio-economic change. It is shown that since flexible systems are less costly to adjust when flood estimates are changing, they justify initially lower safety factors. Investigation on the Value of Flexibility (VoF) demonstrates that VoF depends on the type and degree of uncertainty, on the learning effect (i.e. kind and quality of

  12. A study on the Rate of Knowledge, Attitude and Practice of Medical Students towards Method of Medical Records Documentation at Mazandaran University of Medical Sciences Affiliated Therapeutic and Teaching Centers 2003

    Directory of Open Access Journals (Sweden)

    A. Balaghafari

    2005-01-01

    Full Text Available Background and Objectives: History, clinical findings, procedures undertaken, and patients response to treatment are written in clinical records, hence their contents are indicators of physicians’ evaluation. If clinical records are provided precisely, clear and systematized, they indicate the clinical thinking of the staff and facilitate patients diagnosis process. These records have an important role in coordinating professional staff involved in patient care. Since the physicians and medical students are involved more in medical records documentation than the other hospital staff, thus, a study on their knowledge, attitude and practice towards the principles of medical records documentation is undertaken.Materials and Methods: This is a descriptive study, which is done about the rate of knowledge, attitude and practice of 207 Medical students of Mazandaran University of Medical Sciences in university hospitals. Descriptive and inferential statistical analytic methods were used for the collected data. For comparison of the hospitals, regarding observing designed principals in the completion of medical files, according to the filled questionnaires the minimum and maximum score designated as 1-5 which is very poor to excellent. Then the mean score was calculated and considered for the comparison of hospitals. For the determination of the relationship between knowledge, attitude, and practice, β Kendall’s Tau Test was used.Results: The majority of the participants had low knowledge (77.8% about medical records documentation. Most of them did not have good attitude (54.1 about completion of medical records and significance and value of medical records documentation in treatment, education, and research.Conclusion: Results indicate that incompletion of medical records at the university affiliated hospitals are due to lack of awareness of the students towards the method of medical records documentation. In addition, not considering the

  13. Letter to Editor: Electronic Medical Record, Step toward Improving the Quality of Healthcare Services and Treatment Provided to Patients

    Directory of Open Access Journals (Sweden)

    Elahe Gozali

    2014-04-01

    Full Text Available Information technology can increase the quality of medical care and is a target for many of the pioneers in the development of clinical or medical information. Electronic medical record (EMR, one of such technologies, is a well-known and valuable system to access patient information in hospitals. Electronic medical records which are used for the purpose of providing basic health care are available through a network of computers. All units of the hospital such as examination room, conference room, emergency, patient care units, nursing stations, operating rooms, recovery units, laboratory, radiology, pharmacy and medical records should have access to it. Among its advantages are improved quality of care provided to patients, better organized information, improvement in the timeliness of the process, accuracy and completeness of documentation, patient access to electronic copies of records, prevention of medication errors and allergies, reduced medical errors, immediate access to information in different places, decision support technology and improvement in the process of doing . S urely the use of electronic medical records has created a new dimension to patient care and clinical practice and will provide a comprehensive system to support people in the community and enhance the quality of services provided to them.

  14. Direct-from-patient information on medication use: Protect pregnancy study results

    NARCIS (Netherlands)

    Dreyer, Nancy A.; Mt-Isa, Shahrul; Richardson, Jonathan L.; Laursen, Maja; Zetstra-van der Woude, Priscilla A.; De Jong-Van Den Berg, Lolkje; Jamry-Dziuria, Ana; Thomas, Simon H.L.; Blackburn, Stella C.F.

    2014-01-01

    Background: The PROTECT Pregnancy Study is a non-interventional, prospective study of pregnant women who provide information about medication use and key lifestyle factors at set intervals throughout their pregnancy, and pregnancy outcome. Objectives: This study was designed to pilot new methods of

  15. Identification of a potential fibromyalgia diagnosis using random forest modeling applied to electronic medical records

    Directory of Open Access Journals (Sweden)

    Emir B

    2015-06-01

    Full Text Available Birol Emir,1 Elizabeth T Masters,1 Jack Mardekian,1 Andrew Clair,1 Max Kuhn,2 Stuart L Silverman,3 1Pfizer Inc., New York, NY, 2Pfizer Inc., Groton, CT, 3Cedars-Sinai Medical Center, Los Angeles, CA, USA Background: Diagnosis of fibromyalgia (FM, a chronic musculoskeletal condition characterized by widespread pain and a constellation of symptoms, remains challenging and is often delayed. Methods: Random forest modeling of electronic medical records was used to identify variables that may facilitate earlier FM identification and diagnosis. Subjects aged ≥18 years with two or more listings of the International Classification of Diseases, Ninth Revision, (ICD-9 code for FM (ICD-9 729.1 ≥30 days apart during the 2012 calendar year were defined as cases among subjects associated with an integrated delivery network and who had one or more health care provider encounter in the Humedica database in calendar years 2011 and 2012. Controls were without the FM ICD-9 codes. Seventy-two demographic, clinical, and health care resource utilization variables were entered into a random forest model with downsampling to account for cohort imbalances (<1% subjects had FM. Importance of the top ten variables was ranked based on normalization to 100% for the variable with the largest loss in predicting performance by its omission from the model. Since random forest is a complex prediction method, a set of simple rules was derived to help understand what factors drive individual predictions. Results: The ten variables identified by the model were: number of visits where laboratory/non-imaging diagnostic tests were ordered; number of outpatient visits excluding office visits; age; number of office visits; number of opioid prescriptions; number of medications prescribed; number of pain medications excluding opioids; number of medications administered/ordered; number of emergency room visits; and number of musculoskeletal conditions. A receiver operating

  16. RF-Medisys: a radio frequency identification-based electronic medical record system for improving medical information accessibility and services at point of care.

    Science.gov (United States)

    Ting, Jacky S L; Tsang, Albert H C; Ip, Andrew W H; Ho, George T S

    2011-01-01

    This paper presents an innovative electronic medical records (EMR) system, RF-MediSys, which can perform medical information sharing and retrieval effectively and which is accessible via a 'smart' medical card. With such a system, medical diagnoses and treatment decisions can be significantly improved when compared with the conventional practice of using paper medical records systems. Furthermore, the entire healthcare delivery process, from registration to the dispensing or administration of medicines, can be visualised holistically to facilitate performance review. To examine the feasibility of implementing RF-MediSys and to determine its usefulness to users of the system, a survey was conducted within a multi-disciplinary medical service organisation that operates a network of medical clinics and paramedical service centres throughout Hong Kong Island, the Kowloon Peninsula and the New Territories. Questionnaires were distributed to 300 system users, including nurses, physicians and patients, to collect feedback on the operation and performance of RF-MediSys in comparison with conventional paper-based medical record systems. The response rate to the survey was 67%. Results showed a medium to high level of user satisfaction with the radiofrequency identification (RFID)-based EMR system. In particular, respondents provided high ratings on both 'user-friendliness' and 'system performance'. Findings of the survey highlight the potential of RF-MediSys as a tool to enhance quality of medical services and patient safety.

  17. The Effect of the General Data Protection Regulation on Medical Research

    Science.gov (United States)

    2017-01-01

    Background The enactment of the General Data Protection Regulation (GDPR) will impact on European data science. Particular concerns relating to consent requirements that would severely restrict medical data research have been raised. Objective Our objective is to explain the changes in data protection laws that apply to medical research and to discuss their potential impact. Methods Analysis of ethicolegal requirements imposed by the GDPR. Results The GDPR makes the classification of pseudonymised data as personal data clearer, although it has not been entirely resolved. Biomedical research on personal data where consent has not been obtained must be of substantial public interest. Conclusions The GDPR introduces protections for data subjects that aim for consistency across the EU. The proposed changes will make little impact on biomedical data research. PMID:28235748

  18. An efficient and secure medical image protection scheme based on chaotic maps.

    Science.gov (United States)

    Fu, Chong; Meng, Wei-hong; Zhan, Yong-feng; Zhu, Zhi-liang; Lau, Francis C M; Tse, Chi K; Ma, Hong-feng

    2013-09-01

    Recently, the increasing demand for telemedicine services has raised interest in the use of medical image protection technology. Conventional block ciphers are poorly suited to image protection due to the size of image data and increasing demand for real-time teleradiology and other online telehealth applications. To meet this challenge, this paper presents a novel chaos-based medical image encryption scheme. To address the efficiency problem encountered by many existing permutation-substitution type image ciphers, the proposed scheme introduces a substitution mechanism in the permutation process through a bit-level shuffling algorithm. As the pixel value mixing effect is contributed by both the improved permutation process and the original substitution process, the same level of security can be achieved in a fewer number of overall rounds. The results indicate that the proposed approach provides an efficient method for real-time secure medical image transmission over public networks.

  19. Use of a medical records linkage system to enumerate a dynamic population over time: the Rochester epidemiology project

    National Research Council Canada - National Science Library

    St Sauver, Jennifer L; Grossardt, Brandon R; Yawn, Barbara P; Melton, 3rd, L Joseph; Rocca, Walter A

    2011-01-01

    The Rochester Epidemiology Project (REP) is a unique research infrastructure in which the medical records of virtually all persons residing in Olmsted County, Minnesota, for over 40 years have been linked and archived...

  20. A semantic framework to protect the privacy of electronic health records with non-numerical attributes.

    Science.gov (United States)

    Martínez, Sergio; Sánchez, David; Valls, Aida

    2013-04-01

    Structured patient data like Electronic Health Records (EHRs) are a valuable source for clinical research. However, the sensitive nature of such information requires some anonymisation procedure to be applied before releasing the data to third parties. Several studies have shown that the removal of identifying attributes, like the Social Security Number, is not enough to obtain an anonymous data file, since unique combinations of other attributes as for example, rare diagnoses and personalised treatments, may lead to patient's identity disclosure. To tackle this problem, Statistical Disclosure Control (SDC) methods have been proposed to mask sensitive attributes while preserving, up to a certain degree, the utility of anonymised data. Most of these methods focus on continuous-scale numerical data. Considering that part of the clinical data found in EHRs is expressed with non-numerical attributes as for example, diagnoses, symptoms, procedures, etc., their application to EHRs produces far from optimal results. In this paper, we propose a general framework to enable the accurate application of SDC methods to non-numerical clinical data, with a focus on the preservation of semantics. To do so, we exploit structured medical knowledge bases like SNOMED CT to propose semantically-grounded operators to compare, aggregate and sort non-numerical terms. Our framework has been applied to several well-known SDC methods and evaluated using a real clinical dataset with non-numerical attributes. Results show that the exploitation of medical semantics produces anonymised datasets that better preserve the utility of EHRs.

  1. Brief review: Adoption of electronic medical records to enhance acute pain management.

    Science.gov (United States)

    Goldstein, David H; Phelan, Rachel; Wilson, Rosemary; Ross-White, Amanda; VanDenKerkhof, Elizabeth G; Penning, John P; Jaeger, Melanie

    2014-02-01

    The purpose of this paper is to examine physician barriers to adopting electronic medical records (EMRs) as well as anesthesiologists' experiences with the EMRs used by the acute pain management service at two tertiary care centres in Canada. We first review the recent literature to determine if physician barriers to adoption are changing given the exponential growth of information technology and the evolving healthcare environment. We next report on institutional experience from two academic health sciences centres regarding the challenges they encountered over the past ten years in developing and implementing an electronic medical record system for acute pain management. The key identified barriers to adoption of EMRs are financial, technological, and time constraints. These barriers are identical to those reported in a systematic review performed prior to 2009 and remain significant factors challenging implementation. These challenges were encountered during our institution's process of adopting EMRs specific to acute pain management. In addition, our findings emphasize the importance of physician participation in the development and implementation stages of EMRs in order to incorporate their feedback and ensure the EMR system is in keeping with their workflow. Use of EMRs will inevitably become the standard of care; however, many barriers persist to impede their implementation and adoption. These challenges to implementation can be facilitated by a corporate strategy for change that acknowledges the barriers and provides the resources for implementation. Adoption will facilitate benefits in communication, patient management, research, and improved patient safety.

  2. [Electronic medical records: Evolution of physician-patient relationship in the Primary Care clinic].

    Science.gov (United States)

    Pérez-Santonja, T; Gómez-Paredes, L; Álvarez-Montero, S; Cabello-Ballesteros, L; Mombiela-Muruzabal, M T

    2017-04-01

    The introduction of electronic medical records and computer media in clinics, has influenced the physician-patient relationship. These modifications have many advantages, but there is concern that the computer has become too important, going from a working tool to the centre of our attention during the clinical interview, decreasing doctor interaction with the patient. The objective of the study was to estimate the percentage of time that family physicians spend on computer media compared to interpersonal communication with the patient, and whether this time is modified depending on different variables such as, doctor's age or reason for the consultation. An observational and descriptive study was conducted for 10 weeks, with 2 healthcare centres involved. The researchers attended all doctor- patient interviews, recording the patient time in and out of the consultation. Each time the doctor fixed his gaze on computer media the time was clocked. A total of 436 consultations were collected. The doctors looked at the computer support a median 38.33% of the total duration of an interview. Doctors of 45 years and older spent more time fixing their eyes on computer media (P<.05). Family physicians used almost 40% of the consultation time looking at computer media, and depends on age of physician, number of queries, and number of medical appointments. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

  3. Managing the quality of health information using electronic medical records: an exploratory study among clinical physicians.

    Science.gov (United States)

    Smith, Alan D

    2008-01-01

    As technology is advancing in the healthcare field, ways of reducing costs and improving quality are key initiatives in the tedious processes of operations planning. There are several ways of reducing costs and improving quality management. One such way is the implementation of Electronic Health Records (HERs). A personally interviewed sample from a relatively large healthcare facility located in Pittsburgh, Pennsylvania, which is associated with the University of Pittsburgh Medical Center, netted a total of 44 physicians. There were no statistically significant relationships found based on 'clinicians' willingness to accept Electronic Medical Record (EMR)-embedded systems with gender', 'benefits outweigh risks for EMR-embedded implementation', 'EMR-embedded systems should be mandated', 'EMR-embedded systems should be administered by the federal government', 'EMR-embedded systems should be administered by regional systems', 'EMR applications are an invasion of privacy' and 'IT-related technologies pose an added threat to the healthcare environment'. It was only for the independent variable 'improves quality of care by EMR-embedded implementation' that most physicians felt that such a technology does positively impact patient care.

  4. Efficient Queries of Stand-off Annotations for Natural Language Processing on Electronic Medical Records.

    Science.gov (United States)

    Luo, Yuan; Szolovits, Peter

    2016-01-01

    In natural language processing, stand-off annotation uses the starting and ending positions of an annotation to anchor it to the text and stores the annotation content separately from the text. We address the fundamental problem of efficiently storing stand-off annotations when applying natural language processing on narrative clinical notes in electronic medical records (EMRs) and efficiently retrieving such annotations that satisfy position constraints. Efficient storage and retrieval of stand-off annotations can facilitate tasks such as mapping unstructured text to electronic medical record ontologies. We first formulate this problem into the interval query problem, for which optimal query/update time is in general logarithm. We next perform a tight time complexity analysis on the basic interval tree query algorithm and show its nonoptimality when being applied to a collection of 13 query types from Allen's interval algebra. We then study two closely related state-of-the-art interval query algorithms, proposed query reformulations, and augmentations to the second algorithm. Our proposed algorithm achieves logarithmic time stabbing-max query time complexity and solves the stabbing-interval query tasks on all of Allen's relations in logarithmic time, attaining the theoretic lower bound. Updating time is kept logarithmic and the space requirement is kept linear at the same time. We also discuss interval management in external memory models and higher dimensions.

  5. Efficient Queries of Stand-off Annotations for Natural Language Processing on Electronic Medical Records

    Science.gov (United States)

    Luo, Yuan; Szolovits, Peter

    2016-01-01

    In natural language processing, stand-off annotation uses the starting and ending positions of an annotation to anchor it to the text and stores the annotation content separately from the text. We address the fundamental problem of efficiently storing stand-off annotations when applying natural language processing on narrative clinical notes in electronic medical records (EMRs) and efficiently retrieving such annotations that satisfy position constraints. Efficient storage and retrieval of stand-off annotations can facilitate tasks such as mapping unstructured text to electronic medical record ontologies. We first formulate this problem into the interval query problem, for which optimal query/update time is in general logarithm. We next perform a tight time complexity analysis on the basic interval tree query algorithm and show its nonoptimality when being applied to a collection of 13 query types from Allen’s interval algebra. We then study two closely related state-of-the-art interval query algorithms, proposed query reformulations, and augmentations to the second algorithm. Our proposed algorithm achieves logarithmic time stabbing-max query time complexity and solves the stabbing-interval query tasks on all of Allen’s relations in logarithmic time, attaining the theoretic lower bound. Updating time is kept logarithmic and the space requirement is kept linear at the same time. We also discuss interval management in external memory models and higher dimensions. PMID:27478379

  6. Electronic medical records and communication with patients and other clinicians: are we talking less?

    Science.gov (United States)

    O'Malley, Ann S; Cohen, Genna R; Grossman, Joy M

    2010-04-01

    Commercial electronic medical records (EMRs) both help and hinder physician interpersonal communication--real-time, face-to-face or phone conversations--with patients and other clinicians, according to a new Center for Studying Health System Change (HSC) study based on in-depth interviews with clinicians in 26 physician practices. EMRs assist real-time communication with patients during office visits, primarily through immediate access to patient information, allowing clinicians to talk with patients rather than search for information from paper records. For some clinicians, however, aspects of EMRs pose a distraction during visits. Moreover, some indicated that clinicians may rely on EMRs for information gathering and transfer at the expense of real-time communication with patients and other clinicians. Given time pressures already present in many physician practices, EMR and office-work flow modifications could help ensure that EMRs advance care without compromising interpersonal communication. In particular, policies promoting EMR adoption should consider incorporating communication-skills training for medical trainees and clinicians using EMRs.

  7. Implementation of electronic checklists in an oncology medical record: initial clinical experience.

    Science.gov (United States)

    Albuquerque, Kevin V; Miller, Alexis A; Roeske, John C

    2011-07-01

    The quality of any medical treatment depends on the accurate processing of multiple complex components of information, with proper delivery to the patient. This is true for radiation oncology, in which treatment delivery is as complex as a surgical procedure but more dependent on hardware and software technology. Uncorrected errors, even if small or infrequent, can result in catastrophic consequences for the patient. We developed electronic checklists (ECLs) within the oncology electronic medical record (EMR) and evaluated their use and report on our initial clinical experience. Using the Mosaiq EMR, we developed checklists within the clinical assessment section. These checklists are based on the process flow of information from one group to another within the clinic and enable the processing, confirmation, and documentation of relevant patient information before the delivery of radiation therapy. The clinical use of the ECL was documented by means of a customized report. Use of ECL has reduced the number of times that physicians were called to the treatment unit. In particular, the ECL has ensured that therapists have a better understanding of the treatment plan before the initiation of treatment. An evaluation of ECL compliance showed that, with additional staff training, > 94% of the records were completed. The ECL can be used to ensure standardization of procedures and documentation that the pretreatment checks have been performed before patient treatment. We believe that the implementation of ECLs will improve patient safety and reduce the likelihood of treatment errors.

  8. Effect of educational and electronic medical record interventions on food allergy management.

    Science.gov (United States)

    Zelig, Ari; Harwayne-Gidansky, Ilana; Gault, Allison; Wang, Julie

    2016-09-01

    The growing prevalence of food allergies indicates a responsibility among primary care providers to ensure that their patients receive accurate diagnosis and management. To improve physician knowledge and management of food allergies by implementing educational and electronic medical record interventions. Pre- and posttest scores of pediatric residents and faculty were analyzed to assess the effectiveness of an educational session designed to improve knowledge of food allergy management. One year later, a best practice advisory was implemented in the electronic medical record to alert providers to consider allergy referral whenever a diagnosis code for food allergy or epinephrine autoinjector prescription was entered. A review of charts 6 months before and 6 months after each intervention was completed to determine the impact of both interventions. Outcome measurements included referrals to an allergy clinic, prescription of self-injectable epinephrine, and documentation that written emergency action plans were provided. There was a significant increase in test scores immediately after the educational intervention (mean, 56.2 versus 84.3%; p management of children with food allergies at our pediatrics clinic. Further studies are needed to identify effective strategies to improve management of food allergies by primary care physicians.

  9. Beyond information retrieval and electronic health record use: competencies in clinical informatics for medical education

    Directory of Open Access Journals (Sweden)

    Hersh WR

    2014-07-01

    Full Text Available William R Hersh,1 Paul N Gorman,1 Frances E Biagioli,2 Vishnu Mohan,1 Jeffrey A Gold,3 George C Mejicano4 1Department of Medical Informatics and Clinical Epidemiology, 2Department of Family Medicine, 3Department of Medicine, 4School of Medicine, Oregon Health & Science University, Portland, OR, USA Abstract: Physicians in the 21st century will increasingly interact in diverse ways with information systems, requiring competence in many aspects of clinical informatics. In recent years, many medical school curricula have added content in information retrieval (search and basic use of the electronic health record. However, this omits the growing number of other ways that physicians are interacting with information that includes activities such as clinical decision support, quality measurement and improvement, personal health records, telemedicine, and personalized medicine. We describe a process whereby six faculty members representing different perspectives came together to define competencies in clinical informatics for a curriculum transformation process occurring at Oregon Health & Science University. From the broad competencies, we also developed specific learning objectives and milestones, an implementation schedule, and mapping to general competency domains. We present our work to encourage debate and refinement as well as facilitate evaluation in this area. Keywords: curriculum transformation, clinical decision support, patient safety, health care quality, patient engagement

  10. [Application Status of Evaluation Methodology of Electronic Medical Record: Evaluation of Bibliometric Analysis].

    Science.gov (United States)

    Lin, Dan; Liu, Jialin; Zhang, Rui; Li, Yong; Huang, Tingting

    2015-04-01

    In order to provide a reference and theoretical guidance of the evaluation of electronic medical record (EMR) and establishment of evaluation system in China, we applied a bibliometric analysis to assess the application of methodologies used at home and abroad, as well as to summarize the advantages and disadvantages of them. We systematically searched international medical databases of Ovid-MEDLINE, EBSCOhost, EI, EMBASE, PubMed, IEEE, and China's medical databases of CBM and CNKI between Jan. 1997 and Dec. 2012. We also reviewed the reference lists of articles for relevant articles. We selected some qualified papers according to the pre-established inclusion and exclusion criteria, and did information extraction and analysis to the papers. Eventually, 1 736 papers were obtained from online database and other 16 articles from manual retrieval. Thirty-five articles met the inclusion and exclusion criteria and were retrieved and assessed. In the evaluation of EMR, US counted for 54.28% in the leading place, and Canada and Japan stood side by side and ranked second with 8.58%, respectively. For the application of evaluation methodology, Information System Success Model, Technology Acceptance Model (TAM), Innovation Diffusion Model and Cost-Benefit Access Model were widely applied with 25%, 20%, 12.5% and 10%, respectively. In this paper, we summarize our study on the application of methodologies of EMR evaluation, which can provide a reference to EMR evaluation in China.

  11. Leading change: introducing an electronic medical record system to a paramedic service.

    Science.gov (United States)

    Baird, Shawn; Boak, George

    2016-05-03

    Purpose Leaders in health-care organizations introducing electronic medical records (EMRs) face implementation challenges. The adoption of EMR by the emergency medical and ambulance setting is expected to provide wide-ranging benefits, but there is little research into the processes of adoption in this sector. The purpose of this study is to examine the introduction of EMR in a small emergency care organization and identify factors that aided adoption. Design/methodology/approach Semi-structured interviews with selected paramedics were followed up with a survey issued to all paramedics in the company. Findings The user interfaces with the EMR, and perceived ease of use, were important factors affecting adoption. Individual paramedics were found to have strong and varied preferences about how and when they integrated the EMR into their practice. As company leadership introduced flexibility of use, this enhanced both individual and collective ability to make sense of the change and removed barriers to acceptance. Research limitations/implications This is a case study of one small organization. However, there may be useful lessons for other emergency care organizations adopting EMR. Practical implications Leaders introducing EMR in similar situations may benefit from considering a sense-making perspective and responding promptly to feedback. Originality/value The study contributes to a wider understanding of issues faced by leaders who seek to implement EMRs in emergency medical services, a sector in which there has been to date very little research on this issue.

  12. A patient-identity security mechanism for electronic medical records during transit and at rest.

    Science.gov (United States)

    Chao, Hui-Mei; Twu, Shih-Hsiung; Hsu, Chin-Ming

    2005-09-01

    This paper proposes a patient-identity security mechanism, including an identity cipher/decipher and a user-authentication protocol, to ensure the confidentiality and authentication of patients' electronic medical records (EMRs) during transit and at rest. To support the confidentiality of an EMR, the identity cipher/decipher uses a data-hiding function and three logical-based functions to encrypt/decrypt a patient's identifying data and medical details in an EMR. The ciphertext of the patient's identifying data is patient-EMR related, whereas that of medical details is healthcare agent-EMR related. To support the authentication of an EMR, the user-authentication protocol based on a public key infrastructure uses certificates and dynamic cookies for verification/identification. The identity cipher has been simulated using C programming language running on a 1500 MHz Pentium PC with 512 MB of RAM. The experimental results show that healthcare agents can install large amounts of patients' encrypted EMRs in healthcare databases efficiently. In addition, separately storing the keys in a user's token and an EMR database for decryption increases the safety of patients' EMRs. For each user-authentication trail, the use of certificates and dynamic cookies for verification/identification ensures that only authorized users can obtain access to the EMR, and anyone involved cannot make false claims on the transmission made.

  13. Use of the Electronic Medical Record to Assess Pancreas Size in Type 1 Diabetes

    Science.gov (United States)

    Virostko, John; Hilmes, Melissa; Eitel, Kelsey; Moore, Daniel J.; Powers, Alvin C.

    2016-01-01

    Aims This study harnessed the electronic medical record to assess pancreas volume in patients with type 1 diabetes (T1D) and matched controls to determine whether pancreas volume is altered in T1D and identify covariates that influence pancreas volume. Methods This study included 25 patients with T1D and 25 age-, sex-, and weight-matched controls from the Vanderbilt University Medical Center enterprise data warehouse. Measurements of pancreas volume were made from medical imaging studies using magnetic resonance imaging (MRI) or computed tomography (CT). Results Patients with T1D had a pancreas volume 47% smaller than matched controls (41.16 ml vs. 77.77 ml, P imaging scans displayed progressive declines in pancreas volume over time (~ 6% of volume/year), whereas five controls scanned a year apart did not exhibit a decline in pancreas size (P = 0.03). The pancreas was uniformly smaller on the right and left side of the abdomen. Conclusions Pancreas volume declines with disease duration in patients with T1D, suggesting a protracted pathological process that may include the exocrine pancreas. PMID:27391588

  14. MonDossierMedical.ch - The Personal Health Record for Every Geneva Citizen.

    Science.gov (United States)

    Rosemberg, Aurélie; Schmid, Adian; Plaut, Olivier

    2016-01-01

    MonDossierMedical.ch is a project led by the canton of Geneva, making it possible for every patient to access his own electronic health record (EHR) and to share the medical files with his doctors. It was introduced across the canton in mid-2013, and provided to all patients free of charge. It is based on the first Swiss-wide eHealth-compliant pilot project "e-toile". The canton of Geneva developed "e-toile" as a public-private partnership together with Swiss Post and it was launched in 2011 in some of the canton's municipalities. Back then, Geneva's EHR represented the first Swiss attempt to link all healthcare professionals in the treatment chain. Today, it serves more than 6,000 patients and 400 physicians. This number is growing regularly, as well as the health care institutions (private hospitals, labs) joining the community. The project fits into the national strategy of Switzerland in establishing a national EHR by linking regional implementations like MonDossierMedical.

  15. OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record.

    Science.gov (United States)

    Stoop, Arjen P; Bal, Roland; Berg, Marc

    2007-06-01

    In studies on success and failure of ICT applications in health care, the 'context' is often used to explain the failure of a system and seldom to explain the success of a system. Science and Technology Studies (STS) have showed that for understanding success and failure of phenomena, one has to take a symmetrical approach and thus use the same concept for analyzing success and failure. In this article we analyze the success of OZIS, a communication protocol that makes it possible for pharmacists to exchange medication data by sharing a regionally accessible electronic medication record. Though OZIS serves a common goal - reducing medication errors - the stakeholders that are involved also have other, competing, interests. By focussing on the context and more specifically the interests of the stakeholders, we will show how the success of OZIS can be explained. By doing this, we will also show that this context is highly dynamic and that continuously changing incentives and constraints within the context lead to both facilitating and threatening the success of OZIS.

  16. Does Wearable Medical Technology With Video Recording Capability Add Value to On-Call Surgical Evaluations?

    Science.gov (United States)

    Gupta, Sameer; Boehme, Jacqueline; Manser, Kelly; Dewar, Jannine; Miller, Amie; Siddiqui, Gina; Schwaitzberg, Steven D

    2016-10-01

    Background Google Glass has been used in a variety of medical settings with promising results. We explored the use and potential value of an asynchronous, near-real time protocol-which avoids transmission issues associated with real-time applications-for recording, uploading, and viewing of high-definition (HD) visual media in the emergency department (ED) to facilitate remote surgical consults. Study Design First-responder physician assistants captured pertinent aspects of the physical examination and diagnostic imaging using Google Glass' HD video or high-resolution photographs. This visual media were then securely uploaded to the study website. The surgical consultation then proceeded over the phone in the usual fashion and a clinical decision was made. The surgeon then accessed the study website to review the uploaded video. This was followed by a questionnaire regarding how the additional data impacted the consultation. Results The management plan changed in 24% (11) of cases after surgeons viewed the video. Five of these plans involved decision making regarding operative intervention. Although surgeons were generally confident in their initial management plan, confidence scores increased further in 44% (20) of cases. In addition, we surveyed 276 ED patients on their opinions regarding concerning the practice of health care providers wearing and using recording devices in the ED. The survey results revealed that the majority of patients are amenable to the addition of wearable technology with video functionality to their care. Conclusions This study demonstrates the potential value of a medically dedicated, hands-free, HD recording device with internet connectivity in facilitating remote surgical consultation.

  17. Protective effects of medical ozone combined with traditional Chinese medicine against chemically-induced hepatic injury in dogs

    Institute of Scientific and Technical Information of China (English)

    2007-01-01

    AIM: To investigate the protective effect of medical ozone (O3) combined with Traditional Chinese Medicine (TCM) Yigan Fuzheng Paidu Capsules (YC) against carbon tetrachloride (CCl4)-induced hepatic injury in dogs.METHODS: Thirty healthy dogs were divided randomly into five groups (n = 6 in each group), namely control,oleanolic acid tablet (OAT), O3, YC and O3 + YC, given either no particular pre-treatment, oral OAT, medical ozone rectal insulfflation every other day, oral YC, or oral YC plus medical ozone rectal insulfflation every other day, respectively, for 30 consecutive days. After pre-treatment, acute hepatic injury was induced in all dogs with a single-dose intraperitoneal injection of CCl4.General condition and survival time were recorded.The biochemical and hematological indexes of alanine aminotransferase (ALT), aspartate aminotransferase/alanine aminotransferase (AST/ALT), serum total bilirubin (TBIL), prothrombin time (PT), blood ammonia (AMMO),and blood urea nitrogen (BUN) were measured after CCl4 injection. Hepatic pathological changes were also observed.RESULTS: Compared to the other four groups, the changes of group O3 + YC dogs' general conditions(motoricity, mental state, eating, urination and defecation) could be better controlled. In group O3 +YC the survival rates were higher (P < 0.05 vs group control). AST/ALT values were kept within a normal level in group O3 + YC. Hepatic histopathology showed that hepatic injury in group O3 + YC was less serious than those in the other four groups.CONCLUSION: Medical ozone combined with TCM YC could exert a protective effect on acute liver injury induced by CCl4.

  18. Realization of a universal patient identifier for electronic medical records through biometric technology.

    Science.gov (United States)

    Leonard, D C; Pons, Alexander P; Asfour, Shihab S

    2009-07-01

    The technology exists for the migration of healthcare data from its archaic paper-based system to an electronic one, and, once in digital form, to be transported anywhere in the world in a matter of seconds. The advent of universally accessible healthcare data has benefited all participants, but one of the outstanding problems that must be addressed is how the creation of a standardized nationwide electronic healthcare record system in the United States would uniquely identify and match a composite of an individual's recorded healthcare information to an identified individual patients out of approximately 300 million people to a 1:1 match. To date, a few solutions to this problem have been proposed that are limited in their effectiveness. We propose the use of biometric technology within our fingerprint, iris, retina scan, and DNA (FIRD) framework, which is a multiphase system whose primary phase is a multilayer consisting of these four types of biometric identifiers: 1) fingerprint; 2) iris; 3) retina scan; and 4) DNA. In addition, it also consists of additional phases of integration, consolidation, and data discrepancy functions to solve the unique association of a patient to their medical data distinctively. This would allow a patient to have real-time access to all of their recorded healthcare information electronically whenever it is necessary, securely with minimal effort, greater effectiveness, and ease.

  19. [The role of electronic health records in medical education of persons with diabetes].

    Science.gov (United States)

    Mateljić, Marija; Gaćina, Snjezana

    2014-03-01

    Nursing is faced with a requirement to improve the efficacy of health care services, with complete control of the work processes. The need to use work technology, which implies medical informatics knowledge and skills, arises naturally. While high-quality and best possible treatment depend on numerous factors, electronic record keeping can contribute to quality treatment. Data are entered by all health care providers and the patient. Nurses carry out therapeutic education as the basis of diabetes care. They teach patients self-monitoring or treatment adjustment skills, as well as problem coping procedures and skills, using various didactic tools, written and illustrated materials, audio-visual tools or computer simulations, and keeping electronic nursing records. The patient as an active treatment participant carries out blood glucose self-monitoring by means of quick reading device. This is part of the patient's personal electronic health record, which gives an insight into the individual's response to therapy, and is extremely valuable in the entire treatment.

  20. Predictive modeling of colorectal cancer using a dedicated pre-processing pipeline on routine electronic medical records

    NARCIS (Netherlands)

    Kop, Reinier; Hoogendoorn, Mark; Teije, Annette Ten; Büchner, Frederike L; Slottje, Pauline; Moons, Leon M G; Numans, Mattijs E

    2016-01-01

    Over the past years, research utilizing routine care data extracted from Electronic Medical Records (EMRs) has increased tremendously. Yet there are no straightforward, standardized strategies for pre-processing these data. We propose a dedicated medical pre-processing pipeline aimed at taking on

  1. Improving sensitivity of machine learning methods for automated case identification from free-text electronic medical records

    NARCIS (Netherlands)

    Z. Afzal (Zubair); M.J. Schuemie (Martijn); J.C. van Blijderveen (Nico); E.F. Sen (Fatma); M.C.J.M. Sturkenboom (Miriam); J.A. Kors (Jan)

    2013-01-01

    textabstractBackground: Distinguishing cases from non-cases in free-text electronic medical records is an important initial step in observational epidemiological studies, but manual record validation is time-consuming and cumbersome. We compared different approaches to develop an automatic case iden

  2. The Use of Electronic Medical Records To Facilitate Identification of Patients Presenting With Oro-facial Complaints To The General Medical Practitioners

    OpenAIRE

    Chan, Sze Seng

    2014-01-01

    ABSTRACTThe University of ManchesterSzeSeng ChanMaster of Philosophy in Oral and Maxillofacial SurgeryThe Use of Electronic Medical Records to Facilitate Identification of Patients Presenting With Oro-facial Complaints To The General Medical PractitionersJanuary 2014Aims : To study the pattern of attendance of patients who present to General Medical Practitioners (GMPs) with oro-facial or/and dental complaints. Data Source : All the Primary Medical Cares (PMCs) in the North West e-health data...

  3. How to limit the burden of data collection for Quality Indicators based on medical records? The COMPAQH experience

    Directory of Open Access Journals (Sweden)

    Grenier Catherine

    2008-10-01

    Full Text Available Abstract Background Our objective was to limit the burden of data collection for Quality Indicators (QIs based on medical records. Methods The study was supervised by the COMPAQH project. Four QIs based on medical records were tested: medical record conformity; traceability of pain assessment; screening for nutritional disorders; time elapsed before sending copy of discharge letter to the general practitioner. Data were collected by 6 Clinical Research Assistants (CRAs in a panel of 36 volunteer hospitals and analyzed by COMPAQH. To limit the burden of data collection, we used the same sample of medical records for all 4 QIs, limited sample size to 80 medical records, and built a composite score of only 10 items to assess medical record completeness. We assessed QI feasibility by completing a grid of 19 potential problems and evaluating time spent. We assessed reliability (κ coefficient as well as internal consistency (Cronbach α coefficient in an inter-observer study, and discriminatory power by analysing QI variability among hospitals. Results Overall, 23 115 data items were collected for the 4 QIs and analyzed. The average time spent on data collection was 8.5 days per hospital. The most common feasibility problem was misunderstanding of the item by hospital staff. QI reliability was good (κ: 0.59–0.97 according to QI. The hospitals differed widely in their ability to meet the quality criteria (mean value: 19–85%. Conclusion These 4 QIs based on medical records can be used to compare the quality of record keeping among hospitals while limiting the burden of data collection, and can therefore be used for benchmarking purposes. The French National Health Directorate has included them in the new 2009 version of the accreditation procedure for healthcare organizations.

  4. The Value of Electronic Medical Record Implementation in Mental Health Care: A Case Study.

    Science.gov (United States)

    Riahi, Sanaz; Fischler, Ilan; Stuckey, Melanie I; Klassen, Philip E; Chen, John

    2017-01-05

    Electronic medical records (EMR) have been implemented in many organizations to improve the quality of care. Evidence supporting the value added to a recovery-oriented mental health facility is lacking. The goal of this project was to implement and customize a fully integrated EMR system in a specialized, recovery-oriented mental health care facility. This evaluation examined the outcomes of quality improvement initiatives driven by the EMR to determine the value that the EMR brought to the organization. The setting was a tertiary-level mental health facility in Ontario, Canada. Clinical informatics and decision support worked closely with point-of-care staff to develop workflows and documentation tools in the EMR. The primary initiatives were implementation of modules for closed loop medication administration, collaborative plan of care, clinical practice guidelines for schizophrenia, restraint minimization, the infection prevention and control surveillance status board, drug of abuse screening, and business intelligence. Medication and patient scan rates have been greater than 95% since April 2014, mitigating the adverse effects of medication errors. Specifically, between April 2014 and March 2015, only 1 moderately severe and 0 severe adverse drug events occurred. The number of restraint incidents decreased 19.7%, which resulted in cost savings of more than Can $1.4 million (US $1.0 million) over 2 years. Implementation of clinical practice guidelines for schizophrenia increased adherence to evidence-based practices, standardizing care across the facility. Improved infection prevention and control surveillance reduced the number of outbreak days from 47 in the year preceding implementation of the status board to 7 days in the year following. Decision support to encourage preferential use of the cost-effective drug of abuse screen when clinically indicated resulted in organizational cost savings. EMR implementation allowed Ontario Shores Centre for Mental Health

  5. A study of electronic medical record supporting role on medical research%电子病案对医学科研的支撑作用研究

    Institute of Scientific and Technical Information of China (English)

    胡胜利; 冯骏; 郭伟; 丁悦峰; 曹玮琪

    2015-01-01

    目的 促进病案信息的深度挖掘利用,为临床科研及医院管理提供有力支撑.方法 研究病案信息利用率较低的原因,提出需建设全结构化的无纸化电子病案,最后指出电子病案为科研提供支撑的关键建设要素.结果 指出建设无纸化电子病案要从存储结构化、建设病案系统、与数据仓库等技术相结合入手,同时实现门诊和住院病历互通、建设区域医疗、完善随访系统,最后指出实现的关键技术.结论 这对促进病案的利用率,提高病案对科研的支撑力度,推动医学的发展和进步,提升医院的软实力有着十分重要的意义.%Objective Promote the use of medical record information, the depth of excavation,provide strong support for clinical research and hospital management.Methods Medical Record Information lower utilization reasons put forward need to build the whole structure of the paperless electronic medical records, electronic medical records for research concluded that the key to building elements to provide support.Results Pointed out that the construction of paperless electronic medical records from the storage structure of the building medical record systems, and data warehouse technology combined start, outpatient and inpatient medical records while achieving interoperability, building regional health care, improve follow-up system, and finally pointed out the key technical implementation.Conclusions It is to promote the utilization of medical records, medical records for research to improve support efforts to promote development and progress of medicine and enhance the hospital's soft power has great significance.

  6. Implementing change in primary care practices using electronic medical records: a conceptual framework

    Directory of Open Access Journals (Sweden)

    Stuart Gail W

    2008-01-01

    Full Text Available Abstract Background Implementing change in primary care is difficult, and little practical guidance is available to assist small primary care practices. Methods to structure care and develop new roles are often needed to implement an evidence-based practice that improves care. This study explored the process of change used to implement clinical guidelines for primary and secondary prevention of cardiovascular disease in primary care practices that used a common electronic medical record (EMR. Methods Multiple conceptual frameworks informed the design of this study designed to explain the complex phenomena of implementing change in primary care practice. Qualitative methods were used to examine the processes of change that practice members used to implement the guidelines. Purposive sampling in eight primary care practices within the Practice Partner Research Network-Translating Researching into Practice (PPRNet-TRIP II clinical trial yielded 28 staff members and clinicians who were interviewed regarding how change in practice occurred while implementing clinical guidelines for primary and secondary prevention of cardiovascular disease and strokes. Results A conceptual framework for implementing clinical guidelines into primary care practice was developed through this research. Seven concepts and their relationships were modelled within this framework: leaders setting a vision with clear goals for staff to embrace; involving the team to enable the goals and vision for the practice to be achieved; enhancing communication systems to reinforce goals for patient care; developing the team to enable the staff to contribute toward practice improvement; taking small steps, encouraging practices' tests of small changes in practice; assimilating the electronic medical record to maximize clinical effectiveness, enhancing practices' use of the electronic tool they have invested in for patient care improvement; and providing feedback within a culture of

  7. [Child protection network and the intersector implementation of the circle of security as alternatives to medication].

    Science.gov (United States)

    Becker, Ana Laura Martins M M; de Souza, Paulo Haddad; de Oliveira, Mônica Martins; Paraguay, Nestor Luiz Bruzzi B

    2014-09-01

    To describe the clinical history of a child with aggressive behavior and recurring death-theme speech, and report the experience of the team of authors, who proposed an alternative to medication through the establishment of a protection network and the inter-sector implementation of the circle of security concept. A 5-year-old child has a violent and aggressive behavior at the day-care. The child was diagnosed by the healthcare center with depressive disorder and behavioral disorder, and was medicated with sertraline and risperidone. Side effects were observed, and the medications were discontinued. Despite several actions, such as talks, teamwork, psychological and psychiatric follow-up, the child's behavior remained unchanged. A unique therapeutic project was developed by Universidade Estadual de Campinas' Medical School students in order to establish a connection between the entities responsible for the child's care (daycare center, healthcare center, and family). Thus, the team was able to develop a basic care protection network. The implementation of the inter-sector circle of security, as well as the communication and cooperation among the teams, produced very favorable results in this case. This initiative was shown to be a feasible and effective alternative to the use of medication for this child. Copyright © 2014 Sociedade de Pediatria de São Paulo. Publicado por Elsevier Editora Ltda. All rights reserved.

  8. Confidentiality of the medical records of HIV-positive patients in the United Kingdom – a medicolegal and ethical perspective

    Directory of Open Access Journals (Sweden)

    Mike Williams

    2011-01-01

    Full Text Available Mike WilliamsHead of Service, Cambridge University Dental Service, Cambridge, UKAbstract: This article examines the legal and ethical issues that surround the confidentiality of medical records, particularly in relation to patients who are HIV positive. It records some historical background of the HIV epidemic, and considers the relative risks of transmission of HIV from individual to individual. It explains the law as it pertains to confidentiality, and reports the professional guidance in these matters. It then considers how these relate to HIV-positive individuals in particular.Keywords: HIV/AIDS, confidentiality, medical records

  9. Analysis and Countermeasures on Medical Records Writing Quality%病案书写质量分析与对策

    Institute of Scientific and Technical Information of China (English)

    于弘; 赵莉

    2011-01-01

    目的 提高住院病案书写质量,使医院、医务人员、患者三方的权益得到法律保障.方法 检查某医院2010年第一季度出院病人病案并进行分析.结果 住院病案书写质量,与书写医师性别、职称、科室等因素有关.结论 住院病案的书写仍然存在某些缺陷,需要采取多种对策,提高病案书写质量.%Objective To improve the medical record writing quality, and make sure the rights and interests of hospital, medical staff, and patients are guaranteed by law . Methods Check and analyze medical records of discharged patients in first quarter of 2010. Results The writing quality of medical record is relate to physician gender, job title, department and other factors. Conclusion There are still some shortcomings in medical record writing,various measures should be adopt to improve the writing quality of medical records.

  10. Detecting inpatient falls by using natural language processing of electronic medical records

    Directory of Open Access Journals (Sweden)

    Toyabe Shin-ichi

    2012-12-01

    Full Text Available Abstract Background Incident reporting is the most common method for detecting adverse events in a hospital. However, under-reporting or non-reporting and delay in submission of reports are problems that prevent early detection of serious adverse events. The aim of this study was to determine whether it is possible to promptly detect serious injuries after inpatient falls by using a natural language processing method and to determine which data source is the most suitable for this purpose. Methods We tried to detect adverse events from narrative text data of electronic medical records by using a natural language processing method. We made syntactic category decision rules to detect inpatient falls from text data in electronic medical records. We compared how often the true fall events were recorded in various sources of data including progress notes, discharge summaries, image order entries and incident reports. We applied the rules to these data sources and compared F-measures to detect falls between these data sources with reference to the results of a manual chart review. The lag time between event occurrence and data submission and the degree of injury were compared. Results We made 170 syntactic rules to detect inpatient falls by using a natural language processing method. Information on true fall events was most frequently recorded in progress notes (100%, incident reports (65.0% and image order entries (12.5%. However, F-measure to detect falls using the rules was poor when using progress notes (0.12 and discharge summaries (0.24 compared with that when using incident reports (1.00 and image order entries (0.91. Since the results suggested that incident reports and image order entries were possible data sources for prompt detection of serious falls, we focused on a comparison of falls found by incident reports and image order entries. Injury caused by falls found by image order entries was significantly more severe than falls detected by

  11. Implementing electronic medical record in family practice in Slovenia and other former Yugoslav Republics: Barriers and requirements

    Directory of Open Access Journals (Sweden)

    Kolšek Marko

    2009-01-01

    Full Text Available The author describes problems related to the implementation of electronic medical record in family medicine in Slovenia since 1992 when first personal computers have been delivered to family physicians' practices. The situation of health care informatization and implementation of electronic medical record in primary health care in new countries, other former Yugoslav republics, is described. There are rather big differences among countries and even among some regions of one country, but in the last year the situation improved, especially in Montenegro, Serbia and Slovenia. The main problem that is still unsolved is software offered by several companies which do not offer many functions, are non-standardized or user friendly enough and is not adapted to doctors' needs. Some important questions on medical records are discussed, e.g. what is in fact a medical record, what is its purpose, who uses it, which record is a good one, what should contain and confidentiality issue. The author describes what makes electronic medical record better than paper-based one (above all it is of better quality, efficiency and care-safe, easier in data retrieval and does it offer the possibility of data exchange with other health care professionals and what are the barriers to its wider implementation.

  12. EMRlog method for computer security for electronic medical records with logic and data mining.

    Science.gov (United States)

    Martínez Monterrubio, Sergio Mauricio; Frausto Solis, Juan; Monroy Borja, Raúl

    2015-01-01

    The proper functioning of a hospital computer system is an arduous work for managers and staff. However, inconsistent policies are frequent and can produce enormous problems, such as stolen information, frequent failures, and loss of the entire or part of the hospital data. This paper presents a new method named EMRlog for computer security systems in hospitals. EMRlog is focused on two kinds of security policies: directive and implemented policies. Security policies are applied to computer systems that handle huge amounts of information such as databases, applications, and medical records. Firstly, a syntactic verification step is applied by using predicate logic. Then data mining techniques are used to detect which security policies have really been implemented by the computer systems staff. Subsequently, consistency is verified in both kinds of policies; in addition these subsets are contrasted and validated. This is performed by an automatic theorem prover. Thus, many kinds of vulnerabilities can be removed for achieving a safer computer system.

  13. A genome-wide association study of heparin-induced thrombocytopenia using an electronic medical record

    DEFF Research Database (Denmark)

    Karnes, Jason H; Cronin, Robert M; Rollin, Jerome

    2015-01-01

    . Here, we performed a genome-wide association study (GWAS) and candidate gene study using HIT cases and controls identified using electronic medical records (EMRs) coupled to a DNA biobank and attempted to replicate GWAS associations in an independent cohort. We subsequently investigated influences......-heparin treated patients (OR 3.09; 1.14-8.13; p=0.02). In the candidate gene study, SNPs at HLA-DRA were nominally associated with HIT (OR 0.25; 0.15-0.44; p=2.06×10(-6)). Further study of TDAG8 and HLA-DRA SNPs is warranted to assess their influence on the risk of developing HIT....

  14. EMRlog Method for Computer Security for Electronic Medical Records with Logic and Data Mining

    Directory of Open Access Journals (Sweden)

    Sergio Mauricio Martínez Monterrubio

    2015-01-01

    Full Text Available The proper functioning of a hospital computer system is an arduous work for managers and staff. However, inconsistent policies are frequent and can produce enormous problems, such as stolen information, frequent failures, and loss of the entire or part of the hospital data. This paper presents a new method named EMRlog for computer security systems in hospitals. EMRlog is focused on two kinds of security policies: directive and implemented policies. Security policies are applied to computer systems that handle huge amounts of information such as databases, applications, and medical records. Firstly, a syntactic verification step is applied by using predicate logic. Then data mining techniques are used to detect which security policies have really been implemented by the computer systems staff. Subsequently, consistency is verified in both kinds of policies; in addition these subsets are contrasted and validated. This is performed by an automatic theorem prover. Thus, many kinds of vulnerabilities can be removed for achieving a safer computer system.

  15. Lessons in Medical Record Abstraction from the Prostate, Lung, Colorectal, and Ovarian (PLCO) National Screening Trial.

    Science.gov (United States)

    Bazzi, Latifa; Lamerato, Lois E; Varner, Julie; Shambaugh, Vicki L; Cordes, Jill E; Ragard, Lawrence R; Marcus, Pamela M

    2015-01-01

    The most rigorous and accurate approach to evaluating clinical events in cancer screening studies is to use data obtained through medical record abstraction (MRA). Although MRA is complex, the particulars of the procedure-such as the specific training and quality assurance processes, challenges of implementation, and other factors that influence the quality of abstraction--are usually not described in reports of studies that employed the technique. In this paper, we present the details of MRA activities used in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, which used MRA to determine primary and secondary outcomes and collect data on other clinical events. We describe triggers of the MRA cycle and the specific tasks that were part of the abstraction process. We also discuss training and certification of abstracting staff, and technical methods and communication procedures used for data quality assurance. We include discussion of challenges faced and lessons learned.

  16. EMRlog Method for Computer Security for Electronic Medical Records with Logic and Data Mining

    Science.gov (United States)

    Frausto Solis, Juan; Monroy Borja, Raúl

    2015-01-01

    The proper functioning of a hospital computer system is an arduous work for managers and staff. However, inconsistent policies are frequent and can produce enormous problems, such as stolen information, frequent failures, and loss of the entire or part of the hospital data. This paper presents a new method named EMRlog for computer security systems in hospitals. EMRlog is focused on two kinds of security policies: directive and implemented policies. Security policies are applied to computer systems that handle huge amounts of information such as databases, applications, and medical records. Firstly, a syntactic verification step is applied by using predicate logic. Then data mining techniques are used to detect which security policies have really been implemented by the computer systems staff. Subsequently, consistency is verified in both kinds of policies; in addition these subsets are contrasted and validated. This is performed by an automatic theorem prover. Thus, many kinds of vulnerabilities can be removed for achieving a safer computer system. PMID:26495300

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

    Science.gov (United States)

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

    1995-01-01

    The Institut Municipal d'Assistència Sanitària (IMAS) is a health care organization in Barcelona, comprising two general hospitals, a psychiatric hospital, a surgical clinic, a geriatric center, some primary care clinics, and a research institute. Since 1984, IMAS has been engaged in creating a multicenter integrated hospital information system (IMASIS). Currently, IMASIS offers the possibility to manage administrative data, laboratory results, pathology and cytology reports, radiology reports, and pharmacy inpatient orders; it also shares this information on-line among IMAS centers. IMASIS users may also work with a word processor, a spreadsheet, a database, or a statistical package and have access to MEDLINE. A second phase of IMASIS development began in December 1993 focused on clinical information management. The goal was to move towards an integrated multimedia medical record [1]. As a first step, the implementation experiences of the most advanced hospital information systems around the world were studied. Some of these experiences detected behavioral, cultural, and organizational factors [2] as the main sources of delay, or even failure, in HIS projects. A preliminary analysis to define such factors, assess their potential impact, and introduce adequate measures to deal with them seemed unavoidable before structuring of the project. In our approach to physician attitudes analysis, two survey techniques were applied. First, every hospital service head was contacted to schedule an interview, with either a service representative or a group of staff physicians and residents. The aim was to provide detailed information about project objectives and collect personal opinions, problems encountered in the current HIS, and specific needs of every medical and surgical specialty (including imaging needs). Every service head was asked to distribute a questionnaire among all clinicians, which assessed frequency of use of IMASIS current applications, user's satisfaction

  18. Longitudinal medical records as a complement to routine drug safety signal analysis†

    Science.gov (United States)

    Watson, Sarah; Sandberg, Lovisa; Johansson, Jeanette; Edwards, I. Ralph

    2015-01-01

    Abstract Purpose To explore whether and how longitudinal medical records could be used as a source of reference in the early phases of signal detection and analysis of novel adverse drug reactions (ADRs) in a global pharmacovigilance database. Methods Drug and ADR combinations from the routine signal detection process of VigiBase® in 2011 were matched to combinations in The Health Improvement Network (THIN). The number and type of drugs and ADRs from the data sets were investigated. For unlabelled combinations, graphical display of longitudinal event patterns (chronographs) in THIN was inspected to determine if the pattern supported the VigiBase combination. Results Of 458 combinations in the VigiBase data set, 190 matched to corresponding combinations in THIN (after excluding drugs with less than 100 prescriptions in THIN). Eighteen percent of the VigiBase and 9% of the matched THIN combinations referred to new drugs reported with serious reactions. Of the 112 unlabelled combinations matched to THIN, 52 chronographs were inconclusive mainly because of lack of data; 34 lacked any outstanding pattern around the time of prescription; 24 had an elevation of events in the pre‐prescription period, hence weakened the suspicion of a drug relationship; two had an elevated pattern of events exclusively in the post‐prescription period that, after review of individual patient histories, did not support an association. Conclusions Longitudinal medical records were useful in understanding the clinical context around a drug and suspected ADR combination and the probability of a causal relationship. A drawback was the paucity of data for newly marketed drugs with serious reactions. © 2015 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd. PMID:25623045

  19. Agreement between medical record and parent report for evaluation of childhood febrile seizures.

    Science.gov (United States)

    Ackerson, Bradley K; Sy, Lina S; Yao, Janis F; Craig Cheetham, T; Espinosa-Rydman, Ana M; Jones, Tonia L; Jacobsen, Steven J

    2013-06-12

    The monitoring of vaccine safety is critical to maintaining the public acceptance of vaccines required to ensure their continued success. Methods used to assess adverse events following immunization (AEFI) must accurately reflect their occurrence. Assessment of AEFI is often done via medical record review (MR) or via patient report (PR). However, these sources of data have not previously been compared for the analysis of AEFI. The objective of this study was to evaluate the concordance between MR and PR for young children identified as having had a febrile seizure (FS), an important AEFI, in an integrated health care system. The variables chosen for analysis were those recommended by the Brighton Collaboration Seizure Working Group for the evaluation of generalized seizure as an AEFI [1]. Parent report from phone interviews and mailed questionnaires was compared to abstracted medical records of 110 children with FS between ages 3 and 60 months. Concordance between PR and MR for characteristics and predisposing factors of FS was assessed by percent total agreement and kappa statistic. Percent total agreement between PR and MR was between 43.6 and 100% for variables studied, with 62.5% of items having >70% agreement. However, kappa was poor to fair for all measures (-0.04 to 0.33). While some variables, such as history of seizures in a sibling or parent and several seizure characteristics, were reported more often by PR, other items, such as maximum fever and several concurrent conditions, were reported more often by MR. These findings demonstrate the limitations of using MR or PR alone to assess febrile seizures in children. This analysis supports the practice of collecting data from both MR and PR to most accurately portray the spectrum of predisposing factors and seizure characteristics when evaluating FS in children whenever feasible. Copyright © 2013 Elsevier Ltd. All rights reserved.

  20. Syndromic surveillance in companion animals utilizing electronic medical records data: development and proof of concept

    Directory of Open Access Journals (Sweden)

    Philip H. Kass

    2016-05-01

    Full Text Available In an effort to recognize and address communicable and point-source epidemics in dog and cat populations, this project created a near real-time syndromic surveillance system devoted to companion animal health in the United States. With over 150 million owned pets in the US, the development of such a system is timely in light of previous epidemics due to various causes that were only recognized in retrospect. The goal of this study was to develop epidemiologic and statistical methods for veterinary hospital-based surveillance, and to demonstrate its efficacy by detection of simulated foodborne outbreaks using a database of over 700 hospitals. Data transfer protocols were established via a secure file transfer protocol site, and a data repository was constructed predominantly utilizing open-source software. The daily proportion of patients with a given clinical or laboratory finding was contrasted with an equivalent average proportion from a historical comparison period, allowing construction of the proportionate diagnostic outcome ratio and its confidence interval for recognizing aberrant heath events. A five-tiered alert system was used to facilitate daily assessment of almost 2,000 statistical analyses. Two simulated outbreak scenarios were created by independent experts, blinded to study investigators, and embedded in the 2010 medical records. Both outbreaks were detected almost immediately by the alert system, accurately detecting species affected using relevant clinical and laboratory findings, and ages involved. Besides demonstrating proof-in-concept of using veterinary hospital databases to detect aberrant events in space and time, this research can be extended to conducting post-detection etiologic investigations utilizing exposure information in the medical record.

  1. Determining rates of overweight and obese status in children using electronic medical records

    Science.gov (United States)

    Birken, Catherine S.; Tu, Karen; Oud, William; Carsley, Sarah; Hanna, Miranda; Lebovic, Gerald; Guttmann, Astrid

    2017-01-01

    Abstract Objective To determine the prevalence of overweight and obese status in children by age, sex, and visit type, using data from EMRALD® (Electronic Medical Record Administrative data Linked Database). Design Heights and weights were abstracted for children 0 to 19 years of age who had at least one well-child visit from January 2010 to December 2011. Using the most recent visit, the proportions and 95% CIs of patients defined as overweight and obese were compared by age group, sex, and visit type using the World Health Organization growth reference standards. Setting Ontario. Participants Children 0 to 19 years of age who were rostered to a primary care physician participating in EMRALD and had at least one well-child visit from January 2010 to December 2011. Main outcome measures Proportion and 95% CI of children with overweight and obese status by age group; proportion of children with overweight and obese status by sex (with male sex as the referent) within each age group; and proportion of children with overweight and obese status at the most recent well-child visit type compared with other visit types by age group. Results There were 28 083 well-child visits during this period. For children who attended well-child visits, 84.7% of visits had both a height and weight documented. Obesity rates were significantly higher in 1- to 4-year-olds compared with children younger than 1 (6.1% vs 2.3%; P obesity rates compared with girls. Rates of overweight and obese status were lower using data from well-child visits compared with other visits. Conclusion Electronic medical records might be useful to conduct population-based surveillance of overweight or obese status in children. Methodologic standards, however, should be developed. PMID:28209703

  2. Development and implementation of a 'Mental Health Finder' software tool within an electronic medical record system.

    Science.gov (United States)

    Swan, D; Hannigan, A; Higgins, S; McDonnell, R; Meagher, D; Cullen, W

    2017-02-01

    In Ireland, as in many other healthcare systems, mental health service provision is being reconfigured with a move toward more care in the community, and particularly primary care. Recording and surveillance systems for mental health information and activities in primary care are needed for service planning and quality improvement. We describe the development and initial implementation of a software tool ('mental health finder') within a widely used primary care electronic medical record system (EMR) in Ireland to enable large-scale data collection on the epidemiology and management of mental health and substance use problems among patients attending general practice. In collaboration with the Irish Primary Care Research Network (IPCRN), we developed the 'Mental Health Finder' as a software plug-in to a commonly used primary care EMR system to facilitate data collection on mental health diagnoses and pharmacological treatments among patients. The finder searches for and identifies patients based on diagnostic coding and/or prescribed medicines. It was initially implemented among a convenience sample of six GP practices. Prevalence of mental health and substance use problems across the six practices, as identified by the finder, was 9.4% (range 6.9-12.7%). 61.9% of identified patients were female; 25.8% were private patients. One-third (33.4%) of identified patients were prescribed more than one class of psychotropic medication. Of the patients identified by the finder, 89.9% were identifiable via prescribing data, 23.7% via diagnostic coding. The finder is a feasible and promising methodology for large-scale data collection on mental health problems in primary care.

  3. Tradeoffs of Using Administrative Claims and Medical Records to Identify the Use of Personalized Medicine for Patients with Breast Cancer

    Science.gov (United States)

    Liang, Su-Ying; Phillips, Kathryn A.; Wang, Grace; Keohane, Carol; Armstrong, Joanne; Morris, William M.; Haas, Jennifer S.

    2012-01-01

    Background Administrative claims and medical records are important data sources to examine healthcare utilization and outcomes. Little is known about identifying personalized medicine technologies in these sources. Objectives To describe agreement, sensitivity, and specificity of administrative claims compared to medical records for two pairs of targeted tests and treatments for breast cancer. Research Design Retrospective analysis of medical records linked to administrative claims from a large health plan. We examined whether agreement varied by factors that facilitate tracking in claims (coding and cost) and that enhance medical record completeness (records from multiple providers). Subjects Women (35 – 65 years) with incident breast cancer diagnosed in 2006–2007 (n=775). Measures Use of human epidermal growth factor receptor 2 (HER2) and gene expression profiling (GEP) testing, trastuzumab and adjuvant chemotherapy in claims and medical records. Results Agreement between claims and records was substantial for GEP, trastuzumab, and chemotherapy, and lowest for HER2 tests. GEP, an expensive test with unique billing codes, had higher agreement (91.6% vs. 75.2%), sensitivity (94.9% vs. 76.7%), and specificity (90.1% vs. 29.2%) than HER2, a test without unique billing codes. Trastuzumab, a treatment with unique billing codes, had slightly higher agreement (95.1% vs. 90%) and sensitivity (98.1% vs. 87.9%) than adjuvant chemotherapy. Conclusions Higher agreement and specificity were associated with services that had unique billing codes and high cost. Administrative claims may be sufficient for examining services with unique billing codes. Medical records provide better data for identifying tests lacking specific codes and for research requiring detailed clinical information. PMID:21422962

  4. Extracting Primary Open-Angle Glaucoma from Electronic Medical Records for Genetic Association Studies.

    Directory of Open Access Journals (Sweden)

    Nicole A Restrepo

    Full Text Available Electronic medical records (EMRs are being widely implemented for use in genetic and genomic studies. As a phenotypic rich resource, EMRs provide researchers with the opportunity to identify disease cohorts and perform genotype-phenotype association studies. The Epidemiologic Architecture for Genes Linked to Environment (EAGLE study, as part of the Population Architecture using Genomics and Epidemiology (PAGE I study, has genotyped more than 15,000 individuals of diverse genetic ancestry in BioVU, the Vanderbilt University Medical Center's biorepository linked to a de-identified version of the EMR (EAGLE BioVU. Here we develop and deploy an algorithm utilizing data mining techniques to identify primary open-angle glaucoma (POAG in African Americans from EAGLE BioVU for genetic association studies. The algorithm described here was designed using a combination of diagnostic codes, current procedural terminology billing codes, and free text searches to identify POAG status in situations where gold-standard digital photography cannot be accessed. The case algorithm identified 267 potential POAG subjects but underperformed after manual review with a positive predictive value of 51.6% and an accuracy of 76.3%. The control algorithm identified controls with a negative predictive value of 98.3%. Although the case algorithm requires more downstream manual review for use in large-scale studies, it provides a basis by which to extract a specific clinical subtype of glaucoma from EMRs in the absence of digital photographs.

  5. [General information system through whole hospital and electronic medical record system].

    Science.gov (United States)

    Goto, Takaaki

    2006-02-01

    A new system has been introduced and implemented at the Nagoya City University Hospital since January 2004 in order to improve services for patients and general operation for management of the hospital. General Information System has been consisted with Electronic Medical Record System (EMRS), which is the core of all system and divisional system such as Clinical Laboratory Tests, Images, Medical Accounting and so on. A new system has been built and operated to work with the EMRS at the Department of Central Clinical Laboratory (CCL). To cooperate with the new system, we have constructed and operated directly the EMRS such as automatic registration the latest information on infectious diseases and blood transfusions, clinical reports on laboratory test through the hospital news and/or e-mail, introducing laboratory pre test before the consultation, rapid reports of panic values to the doctor in charge of the patients directly, the new system build up a closer cooperation between division of blood transfusion division and that of immuno-chemistry in CCL through EMRS. The new system has been brought not only efficiency and strengthen of function in CCL but also strengthen the service to patients in the hospital.

  6. The journey from precontemplation to action: Transitioning between electronic medical record systems.

    Science.gov (United States)

    Bentley, Thomas; Rizer, Milisa; McAlearney, Ann Scheck; Mekhjian, Hagop; Siedler, Monica; Sharp, Karen; Teater, Phyllis; Huerta, Timothy

    2016-01-01

    Health care organizations, in response to federal programs, have sought to identify electronic medical record (EMR) strategies that align well with their visions for success. Little exists in the literature discussing the transition from one EMR strategy to another. The analysis and planning process used by a major academic medical center in its journey to adopt a new strategy was described in this study. We use the transtheoretical model of change to frame the five phases through which the organization transitioned from a best-of-breed system to an enterprise system. We explore the five phases of change from the perspective of a maturing approach to new technology adoption. Data collection included archival retrieval and review as well as interviews with key stakeholders. Although there was always a focus on some enterprise capabilities such as computerized physician order entry, the emphasis on EMR selection tended to be driven by specialty requirements. Focusing on the patient across the continuum of care, as opposed to focusing on excessive requirements by clinical specialties, was essential in forming and deploying a vision for the new EMR. This research outlines a successful pathway used by an organization that had invested heavily in EMR technology and was faced with evaluating whether to continue that investment or start with a new platform. Rather than focusing on the technology alone, efforts to reframe the discussion to one that focused on the patient resulted in less resistance to change.

  7. Interconnection of electronic medical record with clinical data management system by CDISC ODM.

    Science.gov (United States)

    Matsumura, Yasushi; Hattori, Atsushi; Manabe, Shiro; Takeda, Toshihiro; Takahashi, Daiyo; Yamamoto, Yuichiro; Murata, Taizo; Mihara, Naoki

    2014-01-01

    EDC system has been used in the field of clinical research. The current EDC system does not connect with electronic medical record system (EMR), thus a medical staff has to transcribe the data in EMR to EDC system manually. This redundant process causes not only inefficiency but also human error. We developed an EDC system cooperating with EMR, in which the data required for a clinical research form (CRF) is transcribed automatically from EMR to electronic CRF (eCRF) and is sent via network. We call this system as "eCRF reporter". The interface module of eCRF reporter can retrieves the data in EMR database including patient biography data, laboratory test data, prescription data and data entered by template in progress notes. The eCRF reporter also enables users to enter data directly to eCRF. The eCRF reporter generates CDISC ODM file and PDF which is a translated form of Clinical data in ODM. After storing eCRF in EMR, it is transferred via VPN to a clinical data management system (CDMS) which can receive the eCRF files and parse ODM. We started some clinical research by using this system. This system is expected to promote clinical research efficiency and strictness.

  8. The effect of electronic medical record adoption on outcomes in US hospitals

    Directory of Open Access Journals (Sweden)

    Lee Jinhyung

    2013-02-01

    Full Text Available Abstract Background The electronic medical record (EMR is one of the most promising components of health information technology. However, the overall impact of EMR adoption on outcomes at US hospitals remains unknown. This study examined the relationship between basic EMR adoption and 30-day rehospitalization, 30-day mortality, inpatient mortality and length of stay. Methods Our overall approach was to compare outcomes for the two years before and two years after the year of EMR adoption, at 708 acute-care hospitals in the US from 2000 to 2007. We looked at the effect of EMR on outcomes using two methods. First, we compared the outcomes by quarter for the period before and after EMR adoption among hospitals that adopted EMR. Second, we compared hospitals that adopted EMR to those that did not, before and after EMR adoption, using a generalized linear model. Results Hospitals adopting EMR experienced 0.11 (95% CI: -0.218 to −0.002 days’ shorter length of stay and 0.182 percent lower 30-day mortality, but a 0.19 (95% CI: 0.0006 to 0.0033 percent increase in 30-day rehospitalization in the two years after EMR adoption. The association of EMR adoption with outcomes also varied by type of admission (medical vs. surgical. Conclusions Previous studies using observational data from large samples of hospitals have produced conflicting results. However, using different methods, we found a small but statistically significant association of EMR adoption with outcomes of hospitalization.

  9. A Technology Acceptance Model for Inter-Organisational Electronic Medical Records Systems

    Directory of Open Access Journals (Sweden)

    Jocelyn Handy

    2001-11-01

    Full Text Available This article reports the findings of the first stage of an ongoing, longitudinal study into the implementation of an interorganisational electronic medical records (EMR system. The study adapted and expanded Davis' (1993 technology acceptance model (TAM to investigate the attitudes of primary care practitioners towards a proposed system for maternity patients. All doctors and midwives holding maternity care contracts with a large urban hospital in New Zealand were sent a questionnaire soliciting their views on a planned EMR system linking the hospital and the primary care sectors. The results showed that whilst Davis' two key factors of perceived ease of use and perceived usefulness were important to medical professionals, another key factor, perceived system acceptability, which concerns control and management of information is vitally important to the acceptance of the system. The study also showed that the two groups of professionals had differing requirements due to different levels of experience and practice computerisation. Finally, the research highlights a number of wider organisational issues particularly relevant to the use of inter organisational systems in general and healthcare systems in particular.

  10. Automatic de-identification of electronic medical records using token-level and character-level conditional random fields.

    Science.gov (United States)

    Liu, Zengjian; Chen, Yangxin; Tang, Buzhou; Wang, Xiaolong; Chen, Qingcai; Li, Haodi; Wang, Jingfeng; Deng, Qiwen; Zhu, Suisong

    2015-12-01

    De-identification, identifying and removing all protected health information (PHI) present in clinical data including electronic medical records (EMRs), is a critical step in making clinical data publicly available. The 2014 i2b2 (Center of Informatics for Integrating Biology and Bedside) clinical natural language processing (NLP) challenge sets up a track for de-identification (track 1). In this study, we propose a hybrid system based on both machine learning and rule approaches for the de-identification track. In our system, PHI instances are first identified by two (token-level and character-level) conditional random fields (CRFs) and a rule-based classifier, and then are merged by some rules. Experiments conducted on the i2b2 corpus show that our system submitted for the challenge achieves the highest micro F-scores of 94.64%, 91.24% and 91.63% under the "token", "strict" and "relaxed" criteria respectively, which is among top-ranked systems of the 2014 i2b2 challenge. After integrating some refined localization dictionaries, our system is further improved with F-scores of 94.83%, 91.57% and 91.95% under the "token", "strict" and "relaxed" criteria respectively.

  11. Tissue Banking, Bioinformatics, and Electronic Medical Records: The Front-End Requirements for Personalized Medicine

    Science.gov (United States)

    Suh, K. Stephen; Sarojini, Sreeja; Youssif, Maher; Nalley, Kip; Milinovikj, Natasha; Elloumi, Fathi; Russell, Steven; Pecora, Andrew; Schecter, Elyssa; Goy, Andre

    2013-01-01

    Personalized medicine promises patient-tailored treatments that enhance patient care and decrease overall treatment costs by focusing on genetics and “-omics” data obtained from patient biospecimens and records to guide therapy choices that generate good clinical outcomes. The approach relies on diagnostic and prognostic use of novel biomarkers discovered through combinations of tissue banking, bioinformatics, and electronic medical records (EMRs). The analytical power of bioinformatic platforms combined with patient clinical data from EMRs can reveal potential biomarkers and clinical phenotypes that allow researchers to develop experimental strategies using selected patient biospecimens stored in tissue banks. For cancer, high-quality biospecimens collected at diagnosis, first relapse, and various treatment stages provide crucial resources for study designs. To enlarge biospecimen collections, patient education regarding the value of specimen donation is vital. One approach for increasing consent is to offer publically available illustrations and game-like engagements demonstrating how wider sample availability facilitates development of novel therapies. The critical value of tissue bank samples, bioinformatics, and EMR in the early stages of the biomarker discovery process for personalized medicine is often overlooked. The data obtained also require cross-disciplinary collaborations to translate experimental results into clinical practice and diagnostic and prognostic use in personalized medicine. PMID:23818899

  12. Clutter in electronic medical records: examining its performance and attentional costs using eye tracking.

    Science.gov (United States)

    Moacdieh, Nadine; Sarter, Nadine

    2015-06-01

    The objective was to use eye tracking to trace the underlying changes in attention allocation associated with the performance effects of clutter, stress, and task difficulty in visual search and noticing tasks. Clutter can degrade performance in complex domains, yet more needs to be known about the associated changes in attention allocation, particularly in the presence of stress and for different tasks. Frequently used and relatively simple eye tracking metrics do not effectively capture the various effects of clutter, which is critical for comprehensively analyzing clutter and developing targeted, real-time countermeasures. Electronic medical records (EMRs) were chosen as the application domain for this research. Clutter, stress, and task difficulty were manipulated, and physicians' performance on search and noticing tasks was recorded. Several eye tracking metrics were used to trace attention allocation throughout those tasks, and subjective data were gathered via a debriefing questionnaire. Clutter degraded performance in terms of response time and noticing accuracy. These decrements were largely accentuated by high stress and task difficulty. Eye tracking revealed the underlying attentional mechanisms, and several display-independent metrics were shown to be significant indicators of the effects of clutter. Eye tracking provides a promising means to understand in detail (offline) and prevent (in real time) major performance breakdowns due to clutter. Display designers need to be aware of the risks of clutter in EMRs and other complex displays and can use the identified eye tracking metrics to evaluate and/or adjust their display. © 2015, Human Factors and Ergonomics Society.

  13. [Children's medical records, HIV and confidentiality: practices and attitudes of physicians and families].

    Science.gov (United States)

    Suesser, P; Letrait, S; Welniarz, B

    2001-12-01

    The aim of this study is to describe the attitudes and practices of doctors and families regarding the use of the individual child health journal, especially by exploring the contradictions between the validity and confidentiality of its content, in particular with respect to HIV infection. In order to accomplish this, both doctors (N = 380) and families (N = 242) were questioned, most of them living and working in Seine-Saint-Denis, the metropolitan district with the third highest prevalence rate of HIV. The findings indicate that: most families are not always prepared to make sure that the confidential use of the child's health journal is maintained, and even less so those affected by HIV; doctors refrain from recording certain psychological and even medical data in the child health journal for fear of the information's misuse within the social sphere; doctors as well as families expressed their preoccupations concerning the confidentiality of the child health journal, essentially with respect to its content and how it is used in various contexts. A number of possibilities are proposed by the study's participants: establish a vaccination record separate from the child health journal, educate parents on how to maintain its confidential use and train the health workers to this end.

  14. Contributing factors to adoption of electronic medical records in otolaryngology offices.

    Science.gov (United States)

    Mahboubi, Hossein; Salibian, Ara A; Wu, Edward C; Patel, Madhukar S; Armstrong, William B

    2013-11-01

    (1) To determine the characteristics of outpatient otolaryngology offices with an electronic medical record (EMR) system, and (2) to compare those characteristics with the trends in surgical and medical specialties. Cross-sectional analysis of U.S. representative data from the National Ambulatory Medical Care Survey (NAMCS). The 2005 to 2010 NAMCS datasets were analyzed. Physicians' specialty was recoded as otolaryngology, all surgical specialties, and all specialties combined. Physician offices with all- or partial-EMR system adoption were then compared to offices without EMR systems with respect to year; geographic region; urban setting; office setting; practice type; practice ownership; employment status; and revenues from Medicare, Medicaid, private insurance, and patient payment. Upon univariate analysis, EMR use was significantly higher among otolaryngology practices located in metropolitan areas and practices run or owned by larger groups of practitioners. Sources of patient revenue did not correlate with the likelihood of EMR use. Multivariate analysis revealed that EMR use by otolaryngologists was significantly associated with group practices and offices owned by institutions. Similar associations were observed with surgical specialties combined in addition to a higher EMR usage in practices with more than 25% of total revenue from private insurance. EMR utilization by otolaryngology practices appears similar to that of other specialties, and is more likely in metropolitan areas and larger practice settings. Despite the announcement of incentive programs under Medicare and Medicaid in 2009, EMR usage was not dependent on the percentage of physicians' total revenue from these sources. Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

  15. The Quality Management of Running Medical Records and the Quality of Medical Care%运行病历的管理与医疗质量

    Institute of Scientific and Technical Information of China (English)

    郑艳平; 李曙光; 唐峰; 石彩霞

    2011-01-01

    Objective To strengthen quality management of running medical records by real-time monitoring. So can improve the quality of care and prevent medical disputes. Methods Quality control department continue to strengthen running medical records quality control since 2008. Check the critical difficult medical records at random once a week in 2008 increased to twice a week in 2009. Check running medical records a total sample of 2, 400 in 2008, and 4,800 in 2009, and analyze the quality of running medical records. Results There were 202 defective medical records in 2008, and the defect rate is 8.42% , 100 defective medical records in 2009, and the defect rate is2.08% . There were statistics significant difference after Chisquare test, P<0.01 . The defective medical records has significantly reduced since 2009. Conclusion To strengthen quality control of running medical records ,find the problems timely and correct them timely, can reduce defects of medical records effectively, w hat's more can improve the medical care quality and ensure the medical care safety .%目的 对运行病历实时监控,以利提高医疗质量、防范医疗纠纷.方法 自2008年起质控科不断加强运行病历质量监控力度,随机抽查科室运行危重疑难病历.由2008年每周一次增加到2009年每周两次.2008年共抽查2400份,2009年共抽查4800份,并分析2008年和2009年运行病历质量.结果 2008年有缺陷病历202份,缺陷率8.42%,2009年有缺陷病历100份,缺陷率2.08%,经卡方检验,P<0.01,统计学有明显差异,表明2009年有缺陷病历的发生率明显减少.病历缺陷项目2009年517个,2008年601个,病历缺陷项目也明显减少.结论 加强运行病历质量监控,及时发现问题及时整改,不仅能有效地减少病历书写缺陷,更重要的是提高了医疗质量,保证了医疗安全.

  16. Electronic health records in outpatient clinics: Perspectives of third year medical students

    Directory of Open Access Journals (Sweden)

    Dobbie Alison E

    2008-03-01

    Full Text Available Abstract Background United States academic medical centers are increasingly incorporating electronic health records (EHR into teaching settings. We report third year medical students' attitudes towards clinical learning using the electronic health record in ambulatory primary care clinics. Methods In academic year 2005–06, 60 third year students were invited to complete a questionnaire after finishing the required Ambulatory Medicine/Family Medicine clerkship. The authors elicited themes for the questionnaire by asking a focus group of third year students how using the EHR had impacted their learning. Five themes emerged: organization of information, access to online resources, prompts from the EHR, personal performance (charting and presenting, and communication with patients and preceptors. The authors added a sixth theme: impact on student and patient follow-up. The authors created a 21-item questionnaire, based on these themes that used a 5-point Likert scale from "Strongly Agree" to "Strongly Disagree". The authors emailed an electronic survey link to each consenting student immediately following their clerkship experience in Ambulatory Medicine/Family Medicine. Results 33 of 53 consenting students (62% returned completed questionnaires. Most students liked the EHR's ability to organize information, with 70% of students responding that essential information was easier to find electronically. Only 36% and 33% of students reported accessing online patient information or clinical guidelines more often when using the EHR than when using paper charts. Most students (72% reported asking more history questions due to EHR prompts, and 39% ordered more clinical preventive services. Most students (69% reported that the EHR improved their documentation. 39% of students responded that they received more feedback on their EHR notes compared to paper chart notes. Only 64% of students were satisfied with the doctor-patient communication with the EHR

  17. Electronic health records in outpatient clinics: Perspectives of third year medical students

    Science.gov (United States)

    Rouf, Emran; Chumley, Heidi S; Dobbie, Alison E

    2008-01-01

    Background United States academic medical centers are increasingly incorporating electronic health records (EHR) into teaching settings. We report third year medical students' attitudes towards clinical learning using the electronic health record in ambulatory primary care clinics. Methods In academic year 2005–06, 60 third year students were invited to complete a questionnaire after finishing the required Ambulatory Medicine/Family Medicine clerkship. The authors elicited themes for the questionnaire by asking a focus group of third year students how using the EHR had impacted their learning. Five themes emerged: organization of information, access to online resources, prompts from the EHR, personal performance (charting and presenting), and communication with patients and preceptors. The authors added a sixth theme: impact on student and patient follow-up. The authors created a 21-item questionnaire, based on these themes that used a 5-point Likert scale from "Strongly Agree" to "Strongly Disagree". The authors emailed an electronic survey link to each consenting student immediately following their clerkship experience in Ambulatory Medicine/Family Medicine. Results 33 of 53 consenting students (62%) returned completed questionnaires. Most students liked the EHR's ability to organize information, with 70% of students responding that essential information was easier to find electronically. Only 36% and 33% of students reported accessing online patient information or clinical guidelines more often when using the EHR than when using paper charts. Most students (72%) reported asking more history questions due to EHR prompts, and 39% ordered more clinical preventive services. Most students (69%) reported that the EHR improved their documentation. 39% of students responded that they received more feedback on their EHR notes compared to paper chart notes. Only 64% of students were satisfied with the doctor-patient communication with the EHR, and 48% stated they spent

  18. Osteopathic manipulative treatment use in the emergency department: a retrospective medical record review.

    Science.gov (United States)

    Ault, Brian; Levy, David

    2015-03-01

    Although the use of osteopathic manipulative treatment (OMT) appears to be declining, data on the use of OMT in the emergency department (ED) are not available. To determine the quantity and characteristics of OMT performed in a single, community academic ED that houses an osteopathic emergency medicine residency. Retrospective medical record review. A single large community academic ED with an osteopathic emergency medicine residency from July 14, 2005, to March 4, 2013. Patients in the ED who received OMT (N=2076). Medical record data were analyzed to determine patient demographics; treatment characteristics including number of procedures and patients per physician, OMT techniques used, night vs day procedure variation, and financial implication of future billing for OMT; chief complaints; primary discharge diagnoses; and length of stay in the ED. Patients were aged 0 to 95 years (mean, 39 years) and were predominately female (1260 [60.69%]) and white (1300 [62.62%]). A mean of 0.74 patients received OMT per day, and a mean of 29.65 procedures were performed per physician. When data for residents were looked at separately, the mean was higher at 40.32 procedures per physician. The top 3 discharge diagnoses were low back pain (189 patients [9.10%]), muscle spasm (106 patients [5.11%]), and spasm: muscle, back (93 patients [4.48%]). Eleven different OMT techniques were recorded, with myofascial release being used most frequently (1150 of 2868 procedures [40.09%]), followed by muscle energy (672 [23.43%]). The average length of stay in the ED was 206 minutes. A total of 1663 OMT procedures (80%) were performed during the day, whereas 413 (20%) were performed at night. Potential procedural billing for all OMT performed during the study period was $33.09 per day. In contrast to perceptions that OMT use is declining, the authors found that OMT is being performed on a near daily basis in the ED. Additional research is needed to fully understand the impact of OMT in the

  19. The Value of Electronic Medical Record Implementation in Mental Health Care: A Case Study

    Science.gov (United States)

    Fischler, Ilan; Stuckey, Melanie I; Klassen, Philip E; Chen, John

    2017-01-01

    Background Electronic medical records (EMR) have been implemented in many organizations to improve the quality of care. Evidence supporting the value added to a recovery-oriented mental health facility is lacking. Objective The goal of this project was to implement and customize a fully integrated EMR system in a specialized, recovery-oriented mental health care facility. This evaluation examined the outcomes of quality improvement initiatives driven by the EMR to determine the value that the EMR brought to the organization. Methods The setting was a tertiary-level mental health facility in Ontario, Canada. Clinical informatics and decision support worked closely with point-of-care staff to develop workflows and documentation tools in the EMR. The primary initiatives were implementation of modules for closed loop medication administration, collaborative plan of care, clinical practice guidelines for schizophrenia, restraint minimization, the infection prevention and control surveillance status board, drug of abuse screening, and business intelligence. Results Medication and patient scan rates have been greater than 95% since April 2014, mitigating the adverse effects of medication errors. Specifically, between April 2014 and March 2015, only 1 moderately severe and 0 severe adverse drug events occurred. The number of restraint incidents decreased 19.7%, which resulted in cost savings of more than Can $1.4 million (US $1.0 million) over 2 years. Implementation of clinical practice guidelines for schizophrenia increased adherence to evidence-based practices, standardizing care across the facility. Improved infection prevention and control surveillance reduced the number of outbreak days from 47 in the year preceding implementation of the status board to 7 days in the year following. Decision support to encourage preferential use of the cost-effective drug of abuse screen when clinically indicated resulted in organizational cost savings. Conclusions EMR implementation

  20. Statement on access to relevant medical and other health records and relevant legal records for forensic medical evaluations of alleged torture and other cruel, inhuman or degrading treatment or punishment.

    Science.gov (United States)

    Alempijevic, D; Beriashvili, R; Beynon, J; Duque, M; Duterte, P; Fernando, R; Fincanci, S; Hansen, S; Hardi, L; Hougen, H; Iacopino, V; Mendonça, M; Modvig, J; Mendez, M; Özkalipci, Ö; Payne-James, J; Peel, M; Rasmussen, O; Reyes, H; Rogde, S; Sajantila, A; Treue, F; Vanezis, P; Vieira, D

    2013-04-01

    In some jurisdictions attempts have been made to limit or deny access to medical records for victims of torture seeking remedy or reparations or for individuals who have been accused of crimes based on confessions allegedly extracted under torture. The following article describes the importance of full disclosure of all medical and other health records, as well as legal documents, in any case in which an individual alleges that they have been subjected to torture or other forms of cruel, inhuman or degrading treatment of punishment. A broad definition of what must be included in the terms medical and health records is put forward, and an overview of why their full disclosure is an integral part of international standards for the investigation and documentation of torture (the Istanbul Protocol). The fact that medical records may reveal the complicity or direct participation of healthcare professionals in acts of torture and other ill-treatment is discussed. A summary of international law and medical ethics surrounding the right of access to personal information, especially health information in connection with allegations of torture is also given.

  1. Use of an Electronic Medication Administration Record (eMAR) for Surveillance of Medication Omissions: Results of a One Year Study of Antimicrobials in the Inpatient Setting

    Science.gov (United States)

    Dalton, Bruce R.; Sabuda, Deana M.; Bresee, Lauren C.; Conly, John M.

    2015-01-01

    Introduction Medication administration omissions (MAO) are usually considered medication errors but not all MAO are clinically relevant. We determined the frequency of clinically relevant MAO of antimicrobial drugs in adult hospitals in Calgary, Alberta, Canada based on electronic medication administration record (eMAR). Methods We examined 2011 data from eMAR records on medical wards and developed a reproducible assessment scheme to categorize and determine clinical relevance of MAO. We applied this scheme to records from 2012 in a retrospective cohort study to quantify clinically relevant MAO. Significant predictors of clinically relevant MAO were identified. Results A total of 294,718 dose records were assessed of which 10,282 (3.49%) were for doses not administered. Among these 4903 (1.66% of total); 47.68% of MAO were considered clinically relevant. Significant positive predictors of clinically relevant MAO included inhaled (OR 4.90, 95% CI 3.54-6.94) and liquid oral (OR 1.32, 95% CI 1.18-1.47) route of medication compared to solid oral and irregular dose schedules. Evening nursing shift compared to night shift (OR 0.77 95% CI 0.70-0.85) and parenteral (OR 0.50, 95% CI 0.46-0.54) were negative predictors, The commonest reasons for relevant MAO were patient preference, unspecified reason, administration access issues, drug not available or patient condition. Conclusion Assessment of MAO by review of computer records provides a greater scope and sample size than directly observed medication administration assessments without “observer” effect. We found that MAO of antimicrobials in inpatients were uncommon but were seen more frequently with orally administered antimicrobials which may have significance to antimicrobial stewardship initiatives. PMID:25856373

  2. Use of an electronic medication administration record (eMAR for surveillance of medication omissions: results of a one year study of antimicrobials in the inpatient setting.

    Directory of Open Access Journals (Sweden)

    Bruce R Dalton

    Full Text Available Medication administration omissions (MAO are usually considered medication errors but not all MAO are clinically relevant. We determined the frequency of clinically relevant MAO of antimicrobial drugs in adult hospitals in Calgary, Alberta, Canada based on electronic medication administration record (eMAR.We examined 2011 data from eMAR records on medical wards and developed a reproducible assessment scheme to categorize and determine clinical relevance of MAO. We applied this scheme to records from 2012 in a retrospective cohort study to quantify clinically relevant MAO. Significant predictors of clinically relevant MAO were identified.A total of 294,718 dose records were assessed of which 10,282 (3.49% were for doses not administered. Among these 4903 (1.66% of total; 47.68% of MAO were considered clinically relevant. Significant positive predictors of clinically relevant MAO included inhaled (OR 4.90, 95% CI 3.54-6.94 and liquid oral (OR 1.32, 95% CI 1.18-1.47 route of medication compared to solid oral and irregular dose schedules. Evening nursing shift compared to night shift (OR 0.77 95% CI 0.70-0.85 and parenteral (OR 0.50, 95% CI 0.46-0.54 were negative predictors, The commonest reasons for relevant MAO were patient preference, unspecified reason, administration access issues, drug not available or patient condition.Assessment of MAO by review of computer records provides a greater scope and sample size than directly observed medication administration assessments without "observer" effect. We found that MAO of antimicrobials in inpatients were uncommon but were seen more frequently with orally administered antimicrobials which may have significance to antimicrobial stewardship initiatives.

  3. 78 FR 28241 - Notice of Approval of Record of Decision for Plan To Protect and Restore Native Ecosystems by...

    Science.gov (United States)

    2013-05-14

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF THE INTERIOR National Park Service Notice of Approval of Record of Decision for Plan To Protect and Restore Native Ecosystems by Managing Non-Native Ungulates, Hawaii Volcanoes National Park, Hawaii AGENCY: National Park...

  4. How to Enhance Quality Management on Medical Records%如何加强病案质量管理

    Institute of Scientific and Technical Information of China (English)

    王冠英; 郑新瑞; 王宏斌; 张珊红

    2012-01-01

    The quality of the medical records management is an important constituent of overall hospital quality management. This article introduces methods and experience of the medical records quality management from how to construct medical records quality management system, perfect regulations and implement it, strengthen training, promote the process quality control, constantly update and perfect the system of rewards and penalties.%病案质量管理是医院质量管理的重要组成部分.从建立健全三级病案质控体系、完善规章制度、强化培训、加强环节控制、优化反馈流程、落实奖惩等6方面,介绍了病案质量管理的主要做法.

  5. How Does Iranian's Legal System Protect Human Vulnerability and Personal Integrity in Medical Research?

    Science.gov (United States)

    Karoubi, Mohammad Taghi; Akhondi, Mohammad Mehdi

    2011-01-01

    The astonishing advance of medical science in recent decades has had endless advantages for humans, including improved level of health, prevention of disease and advances in treatment. These advances depend to a great extent on conducting continuous research. However, besides its enormous advantages, the sole interest of medical science undermines the principles of respect for human vulnerability and personal integrity, in both positive and negative approaches. The positive approach refers to the people who participate in research and practice, while the negative approach refers to people who are deprived of research and practice. The authors of this work, based on legal or moral grounds try to analyse the tension between the principle of respect for human vulnerability and personal integrity and the interest of medical science. Undoubtedly, in applying scientific knowledge and medical practice human vulnerability should be taken into account. In this regard, especially vulnerable individuals and groups should be protected and the personal integrity of such individuals respected. In the light of the merits of Islamic law, this paper is designed to examine the significance of the principles of human vulnerability and personal integrity in medical research by studying the international documents as formalised by UNESCO in order to explore the place of these principles in the Iranian legal system. PMID:23408269

  6. Quality of Co-Prescribing NSAID and Gastroprotective Medications for Elders in The Netherlands and Its Association with the Electronic Medical Record.

    Directory of Open Access Journals (Sweden)

    Dedan Opondo

    Full Text Available To assess guideline adherence of co-prescribing NSAID and gastroprotective medications for elders in general practice over time, and investigate its potential association with the electronic medical record (EMR system brand used.We included patients 65 years and older who received NSAIDs between 2005 and 2010. Prescription data were extracted from EMR systems of GP practices participating in the Dutch NIVEL Primary Care Database. We calculated the proportion of NSAID prescriptions with co-prescription of gastroprotective medication for each GP practice at intervals of three months. Association between proportion of gastroprotection, brand of electronic medical record (EMR, and type of GP practice were explored. Temporal trends in proportion of gastroprotection between electronic medical records systems were analyzed using a random effects linear regression model.We included 91,521 patient visits with NSAID prescriptions from 77 general practices between 2005 and 2010. Overall proportion of NSAID prescriptions to the elderly with co-prescription of gastroprotective medication was 43%. Mean proportion of gastroprotection increased from 27% (CI 25-29% in the first quarter of 2005 with a rate of 1.2% every 3 months to 55%(CI 52-58% at the end of 2010. Brand of EMR and type of GP practice were independently associated with co-prescription of gastroprotection.Although prescription of gastroprotective medications to elderly patients who receive NSAIDs increased in The Netherlands, they are not co-prescribed in about half of the indicated cases. Brand of EMR system is associated with differences in prescription of gastroprotective medication. Optimal design and utilization of EMRs is a potential area of intervention to improve quality of prescription.

  7. Electronic Medical Record System Based on XML%基于XML的电子病历系统

    Institute of Scientific and Technical Information of China (English)

    陈可

    2012-01-01

    According to the problems of medical information transmission delaying and time consuming of browsing anamnesis in the hand-writing medical records, the design solution of the electronic medical record based on XML was raised and complemented. By the development platform of Web Services, the clinical information centered by patients was integrated by the support of EMR, including the physical orders, medical technical inspections, nursing care and infectious diseases' reports. And the information query and integration was implemented in the system. By applying the electronic medical record system, supervision on medical records from multi-direction is being substituted for emphasis on terminal quality control only in hand-writing medical records.%文章针对传统病历书写中存在的医疗信息传递慢,历史病历调阅繁琐等问题,提出并实现了基于XML技术的电子病历系统设计方案.该系统作为临床信息数据的载体,以患者诊疗信息为主线,借助Web Services开发平台,集成了医嘱、医技、护理及传染病报病等信息,实现了数据查询与集成.本系统克服了传统手写病历管理只重病历的终末监控的问题,强化了对病历的多点、多方位监控.

  8. Differing perspectives on parent access to their child's electronic medical record during neonatal intensive care hospitalization: a pilot study.

    Science.gov (United States)

    Chung, Rebecca K; Kim, Una Olivia; Basir, Mir Abdul

    2017-04-10

    To improve informed medical decision-making, principles for family-centered neonatal care recommend that parents have access to their child's medical record on an ongoing basis during neonatal intensive unit care (NICU) hospitalization. Currently, many NICUs do not allow independent parent access to their child's electronic medical record (EMR) during hospitalization. We undertook a cross-sectional survey pilot study of medical professionals and parents to explore opinions regarding this practice. Inclusion criteria: 18-years old, English-literate, legal guardian of patients admitted to the NICU for 14 days. NICU medical professionals included physicians, nurse practitioners, nurses, and respiratory therapists. Medical professionals believed parent access would make their work more difficult, increase time documenting and updating families, making them more liable to litigation and hesitant to chart sensitive information. However, parents felt that they lacked control over their child's care and desired direct access to the EMR. Parents believed this would improve accuracy of their child's medical chart, and increase advocacy and understanding of their child's illness. NICU parents and medical professionals have differing perspectives on independent parental access to their child's EMR. More research is needed to explore the potential of independent parental EMR access to further improve family-centered neonatal care.

  9. Validation of metabolic syndrome using medical records in the SUN cohort

    Directory of Open Access Journals (Sweden)

    Barrio-Lopez Maria

    2011-11-01

    Full Text Available Abstract Background The objective of this study was to evaluate the validity of self reported criteria of Metabolic Syndrome (MS in the SUN (Seguimiento Universidad de Navarra cohort using their medical records as the gold standard. Methods We selected 336 participants and we obtained MS related data according to Adult Treatment Panel III (ATP III and International Diabetes Federation (IDF. Then we compared information on the self reported diagnosis of MS and MS diagnosed in their medical records. We calculated the proportion of confirmed MS, the proportion of confirmed non-MS and the intraclass correlation coefficients for each component of the MS. Results From those 336 selected participants, we obtained sufficient data in 172 participants to confirm or reject MS using ATP III criteria. The proportion of confirmed MS was 91.2% (95% CI: 80.7- 97.1 and the proportion of confirmed non-MS was 92.2% (95% CI: 85.7-96.4 using ATP III criteria. The proportion of confirmed MS using IDF criteria was 100% (95% CI: 87.2-100 and the proportion of confirmed non-MS was 97.1% (95% CI: 85.1-99.9. Kappa Index was 0.82 in the group diagnosed by ATP III criteria and 0.97 in the group diagnosed by IDF criteria. Intraclass correlation coefficients for the different component of MS were: 0.93 (IC 95%:0.91- 0.95 for BMI; 0.96 (IC 95%: 0.93-0.98 for waist circumference; 0.75 (IC 95%: 0.66-0.82 for fasting glucose; 0.50 (IC 95%:0.35-0.639 for HDL cholesterol; 0.78 (IC 95%: 0.70-0.84 for triglycerides; 0.49 (IC 95%:0.34-0.61 for systolic blood pressure and 0.55 (IC 95%: 0.41-0.65 for diastolic blood pressure. Conclusions Self-reported MS based on self reported components of the SM in a Spanish cohort of university graduates was sufficiently valid as to be used in epidemiological studies.

  10. [Morbidity and drug consumption. Comparison of results between the National Health Survey and electronic medical records].

    Science.gov (United States)

    Aguilar-Palacio, Isabel; Carrera-Lasfuentes, Patricia; Poblador-Plou, Beatriz; Prados-Torres, Alexandra; Rabanaque-Hernández, M José

    2014-01-01

    To compare the prevalence of disease and drug consumption obtained by using the National Health Survey (NHS) with the information provided by the electronic medical records (EMR) in primary health care and the Pharmaceutical Consumption Registry in Aragon (Farmasalud) in the adult population in the province of Zaragoza. A cross-sectional study was performed to compare the prevalence of diseases in the NHS-2006 and in the EMR. The prevalence of drug consumption was obtained from the NHS-2006 and Farmasalud. Estimations using each database were compared with their 95% confidence intervals (95% CI) and the results were stratified by gender and age groups. The comparability of the databases was tested. According to the NHS, a total of 81.8% of the adults in the province of Zaragoza visited a physician in 2006. According to the EMR, 61.4% of adults visited a primary care physician. The most prevalent disease in both databases was hypertension (NHS: 21.5%, 95% CI: 19.4-23.9; EMR: 21.6%, 95% CI: 21.3-21.8). The greatest differences between the NHS and EMR was observed in the prevalence of depression, anxiety, and other mental illnesses (NHS: 10.9%; EMR: 26.6%). The most widely consumed drugs were analgesics The prevalence of drug consumption differed in the two databases, with the greatest differences being found in pain medication (NHS: 23.3%; Farmasalud: 63.8%) and antibiotics (NHS: 3.4%; Farmasalud: 41.7%). These differences persisted after we stratified by gender and were especially important in the group aged more than 75 years. The prevalence of morbidity and drug consumption differed depending on the database employed. The use of different databases is recommended to estimate real prevalences. Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.

  11. Pediatric patients on ketogenic diet undergoing general anesthesia-a medical record review.

    Science.gov (United States)

    Soysal, Elif; Gries, Heike; Wray, Carter

    2016-12-01

    To identify guidelines for anesthesia management and determine whether general anesthesia is safe for pediatric patients on ketogenic diet (KD). Retrospective medical record review. Postoperative recovery area. All pediatric patients who underwent general anesthesia while on KD between 2009 and 2014 were reviewed. We identified 24 patients who underwent a total of 33 procedures. All children were on KD due to intractable epilepsy. The age of patients ranged from 1 to 15 years. General anesthesia for the scheduled procedures. Patients' demographics, seizure history, type of procedure; perioperative blood chemistry, medications including the anesthesia administered, and postoperative complications. Twenty-four patients underwent a total of 33 procedures. The duration of KD treatment at the time of general anesthesia ranged from 4 days to 8 years. Among the 33 procedures, 3 patients had complications that could be attributable to KD and general anesthesia. A 9-year-old patient experienced increased seizures on postoperative day 0. An 8-year-old patient with hydropcephalus developed metabolic acidosis on postoperative day 1, and a 7-year-old patient's procedure was complicated by respiratory distress and increased seizure activity in the postanesthesia care unit. This study showed that it is relatively safe for children on KD to undergo general anesthesia. The 3 complications attributable to general anesthesia were mild, and the increased seizure frequencies in 2 patients returned back to baseline in 24 hours. Although normal saline is considered more beneficial than lactated Ringer's solution in patients on KD, normal saline should also be administered carefully because of the risk of exacerbating patients' metabolic acidosis. One should be aware of the potential change of the ketogenic status due to drugs given intraoperatively. Copyright © 2016 Elsevier Inc. All rights reserved.

  12. Modeling Patient Treatment With Medical Records: An Abstraction Hierarchy to Understand User Competencies and Needs.

    Science.gov (United States)

    St-Maurice, Justin D; Burns, Catherine M

    2017-07-28

    Health care is a complex sociotechnical system. Patient treatment is evolving and needs to incorporate the use of technology and new patient-centered treatment paradigms. Cognitive work analysis (CWA) is an effective framework for understanding complex systems, and work domain analysis (WDA) is useful for understanding complex ecologies. Although previous applications of CWA have described patient treatment, due to their scope of work patients were previously characterized as biomedical machines, rather than patient actors involved in their own care. An abstraction hierarchy that characterizes patients as beings with complex social values and priorities is needed. This can help better understand treatment in a modern approach to care. The purpose of this study was to perform a WDA to represent the treatment of patients with medical records. The methods to develop this model included the analysis of written texts and collaboration with subject matter experts. Our WDA represents the ecology through its functional purposes, abstract functions, generalized functions, physical functions, and physical forms. Compared with other work domain models, this model is able to articulate the nuanced balance between medical treatment, patient education, and limited health care resources. Concepts in the analysis were similar to the modeling choices of other WDAs but combined them in as a comprehensive, systematic, and contextual overview. The model is helpful to understand user competencies and needs. Future models could be developed to model the patient's domain and enable the exploration of the shared decision-making (SDM) paradigm. Our work domain model links treatment goals, decision-making constraints, and task workflows. This model can be used by system developers who would like to use ecological interface design (EID) to improve systems. Our hierarchy is the first in a future set that could explore new treatment paradigms. Future hierarchies could model the patient as a

  13. Cost, staffing and quality impact of bedside electronic medical record (EMR) in nursing homes.

    Science.gov (United States)

    Rantz, Marilyn J; Hicks, Lanis; Petroski, Gregory F; Madsen, Richard W; Alexander, Greg; Galambos, Colleen; Conn, Vicki; Scott-Cawiezell, Jill; Zwygart-Stauffacher, Mary; Greenwald, Leslie

    2010-09-01

    There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes. Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures. Total costs increased in both intervention groups that implemented technology; staffing and staff retention remained constant. Improvement trends were detected in resident outcomes of ADLs, range of motion, and high-risk pressure sores for both intervention groups but not in comparison groups. Implementation of bedside EMR is not cost neutral. There were increased total costs for all intervention facilities. These costs were not a result of increased direct care staffing or increased staff turnover. Nursing home leaders and policy makers need to be aware of on-going hardware and software costs as well as costs of continual technical support for the EMR and constant staff orientation to use the system. EMR can contribute to the quality of nursing home care and can be enhanced by on-site consultation by nurses with graduate education in nursing and expertise in gerontology. Copyright 2010 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.

  14. A Examine and Verify Mode of the Front Sheet of Medical Record Based on Electronic Medical Records%一种基于电子病历的首页审核模式介绍

    Institute of Scientific and Technical Information of China (English)

    王平根; 符祥敏; 吴葳; 罗文龙

    2015-01-01

    This paper introduces a kind of electronic medical record front sheet audit mode. The model under the background of electronic medical record system construction,adhere to the principle of the international classification of diseases "coding dominant", classification of diagnosis and clinical diagnosis of seeking common ground while putting aside differences",medical record management personnel and medical staff good communication and interaction, review process step-by-step", the multi-level, multi-angle training on the basis of the step by step. This mode optimize the medical record management and clinical departments work flow, promotes the medical record management idea transformation, promote the construction of the hospital information system, improve the working efficiency, has obtained the good effect.%本文介绍了我院的一种电子病历首页审核模式。该模式在医院电子病历系统建设背景下,坚持国际疾病分类“编码主导”、分类诊断与临床诊断“求同存异”、病案管理人员与医护人员良好“沟通互动”、审核过程“分步实施”为原则,并在多层次、多角度培训的基础上得以循序渐进地进行。模式的实施优化了病案管理与临床科室工作流程,促进了全院病案管理理念转变,推动了医院信息系统建设,提高了工作效率,取得了良好效果。

  15. Influence of pharmacy practice on community pharmacists' integration of medication and lab value information from electronic health records.

    Science.gov (United States)

    Hughes, Christine A; Guirguis, Lisa M; Wong, Timothy; Ng, Karen; Ing, Lesley; Fisher, Kyle

    2011-01-01

    To describe how an electronic health record (EHR) was integrated into community pharmacists' patterns of patient care and to explore factors that are related to the use of medication and laboratory value information from the EHR. Descriptive, exploratory, nonexperimental study. Edmonton, Canada, between November 2008 and March 2009. 16 pharmacists, 3 pharmacy technicians, and 2 pharmacy interns from primary care networks, long-term care settings, community independent and chain pharmacies, and grocery store pharmacies. Qualitative interviews. Pharmacists' self-reported use of EHR. Pharmacists in a patient-centered care practice (involving medication therapy management activities) were more likely to adopt the EHR for medication history and laboratory values, whereas pharmacists whose practice was focused on medication dispensing primarily used the EHR for patient demographic and dispensing records. Six general factors influenced the use of EHR: patients, pharmacists, pharmacy, other health professionals (i.e., physicians), EHR, and environment. Access to the medical record versus EHR and timeliness were barriers specific to pharmacists in a patient-centered practice. Factors that affected EHR use for pharmacists with primarily a dispensing practice were role understanding, dispensing versus lab records, valid reasons for using EHR, and fear of legal and disciplinary issues. Many community pharmacists embraced the EHR as a part of practice change, particularly those in patient-centered care practices. Practice type (patient-centered care or dispensing) greatly influenced pharmacists' use of EHR, specifically laboratory values. Because these qualitative findings are exploratory in nature, they may not be generalized beyond the participating pharmacies.

  16. Using technology to teach technology: design and evaluation of bilingual online physician education about electronic medical records.

    Science.gov (United States)

    Edmonson, Sarah R; Esquivel, Adol; Mokkarala, Pallavi; Johnson, Craig W; Phelps, Cynthia L

    2005-01-01

    The "EMR Tutorial" is designed to be a bilingual online physician education environment about electronic medical records. After iterative assessment and redesign, the tutorial was tested in two groups: U.S. physicians and Mexican medical students. Split-plot ANOVA revealed significantly different pre-test scores in the two groups, significant cognitive gains for the two groups overall, and no significant difference in the gains made by the two groups. Users rated the module positively on a satisfaction questionnaire.

  17. Structured Data Entry in the Electronic Medical Record: Perspectives of Pediatric Specialty Physicians and Surgeons.

    Science.gov (United States)

    Bush, Ruth A; Kuelbs, Cynthia; Ryu, Julie; Jiang, Wen; Chiang, George

    2017-05-01

    The Epic electronic health record (EHR) platform supports structured data entry systems (SDES), which allow developers, with input from users, to create highly customized patient-record templates in order to maximize data completeness and to standardize structure. There are many potential advantages of using discrete data fields in the EHR to capture data for secondary analysis and epidemiological research, but direct data acquisition from clinicians remains one of the largest obstacles to leveraging the EHR for secondary use. Physician resistance to SDES is multifactorial. A 35-item questionnaire based on Unified Theory of Acceptance and Use of Technology, was used to measure attitudes, facilitation, and potential incentives for adopting SDES for clinical documentation among 25 pediatric specialty physicians and surgeons. Statistical analysis included chi-square for categorical data as well as independent sample t-tests and analysis of variance for continuous variables. Mean scores of the nine constructs demonstrated primarily positive physician attitudes toward SDES, while the surgeons were neutral. Those under 40 were more likely to respond that facilitating conditions for structured entry existed as compared to the two older age groups (p = .02). Pediatric surgeons were significantly less positive than specialty physicians about SDES effects on Performance (p = .01) and the effect of Social Influence (p = .02); but in more agreement that use of forms was voluntary (p = .02). Attitudinal differences likely reflect medical training, clinical practice workflows, and division specific practices. Identified resistance indicate efforts to increase SDES adoption should be discipline-targeted rather than a uniform approach.

  18. The Computerized Medical Record as a Tool for Clinical Governance in Australian Primary Care

    Science.gov (United States)

    Phillips, Christine; Hall, Sally; Travaglia, Joanne

    2013-01-01

    Background Computerized medical records (CMR) are used in most Australian general practices. Although CMRs have the capacity to amalgamate and provide data to the clinician about their standard of care, there is little research on the way in which they may be used to support clinical governance: the process of ensuring quality and accountability that incorporates the obligation that patients are treated according to best evidence. Objective The objective of this study was to explore the capability, capacity, and acceptability of CMRs to support clinical governance. Methods We conducted a realist review of the role of seven CMR systems in implementing clinical governance, developing a four-level maturity model for the CMR. We took Australian primary care as the context, CMR to be the mechanism, and looked at outcomes for individual patients, localities, and for the population in terms of known evidence-based surrogates or true outcome measures. Results The lack of standardization of CMRs makes national and international benchmarking challenging. The use of the CMR was largely at level two of our maturity model, indicating a relatively simple system in which most of the process takes place outside of the CMR, and which has little capacity to support benchmarking, practice comparisons, and population-level activities. Although national standards for coding and projects for record access are proposed, they are not operationalized. Conclusions The current CMR systems can support clinical governance activities; however, unless the standardization and data quality issues are addressed, it will not be possible for current systems to work at higher levels. PMID:23939340

  19. Analysis on Defects of 5648 Discharge Medical Records%5684例出院记录缺陷分析

    Institute of Scientific and Technical Information of China (English)

    王珩; 潘秀莺; 李鹏

    2011-01-01

    目的 规范出院记录书写和确保出院记录质量.方法 按照安徽省卫生厅对出院记录的要求,自设调查表,将缺陷分为12项指标,对5684份出院记录常见缺陷调查.结果 存在缺陷的记录2554份,缺陷率45%,缺失项目现象严重.结论 出院记录质量亟待提高,需解决深层次原因.%Objective To ensure the writing quality of discharge medical records.Methods In accordance with the requirement on the discharge medical records by basic norms of medical records writing of the Anhui Province health department and creating our own survey, and dividing the defects into 12 indexes, investigating common defects of 5684 discharge records from a "top class and A grade" hospital.Results Defect rate is 45% , the departments with operations have higher defect rate and lack of dose usage is in the first place among these defects.Conclusion It is very urgent to improve the quality of discharge medical records and its deep-seated reasons should be found out.Intensifying educations, perfecting regulatory and strengthening the self-assessment and peer reviews are necessary means.

  20. Adding Live-Streaming to Recorded Lectures in a Non-Distributed Pre-Clerkship Medical Education Model.

    Science.gov (United States)

    Sandhu, Amanjot; Fliker, Aviva; Leitao, Darren; Jones, Jodi; Gooi, Adrian

    2017-01-01

    Live-streaming video has had increasing uses in medical education, especially in distributed education models. The literature on the impact of live-streaming in non-distributed education models, however, is scarce. To determine the attitudes towards live-streaming and recorded lectures as a resource to pre-clerkship medical students in a non-distributed medical education model. First and second year medical students were sent a voluntary cross-sectional survey by email, and were asked questions on live-streaming, recorded lectures and in person lectures using a 5-point Likert and open answers. Of the 118 responses (54% response rate), the data suggested that both watching recorded lectures (Likert 4.55) and live-streaming lectures (4.09) were perceived to be more educationally valuable than face-to-face attendance of lectures (3.60). While responses indicated a statistically significant increase in anticipated classroom attendance if both live-streaming and recorded lectures were removed (from 63% attendance to 76%, p =0.002), there was no significant difference in attendance if live-streaming lectures were removed but recorded lectures were maintained (from 63% to 66%, p=0.76). The addition of live-streaming lectures in the pre-clerkship setting was perceived to be value added to the students. The data also suggests that the removal of live-streaming lectures would not lead to a statistically significant increase in classroom attendance by pre-clerkship students.

  1. Feasibility of ensuring confidentiality and security of computer-based patient records. Council on Scientific Affairs, American Medical Association.

    Science.gov (United States)

    1993-05-01

    Legal and ethical precepts that apply to paper-based medical records, including requirements that patient records be kept confidential, accurate and legible, secure, and free from unauthorized access, should also apply to computer-based patient records. Sources of these precepts include federal regulations, state medical practice acts, licensing statutes and the regulations that implement them, accreditation standards, and professional codes of ethics. While the legal and ethical principles may not change, the risks to confidentiality and security of patient records appear to differ between paper- and computer-based records. Breaches of system security, the potential for faulty performance that may result in inaccessibility or loss of records, the increased technical ability to collect, store, and retrieve large quantities of data, and the ability to access records from multiple and (sometimes) remote locations are among the risk factors unique to computer-based record systems. Managing these risks will require a combination of reliable technological measures, appropriate institutional policies and governmental regulations, and adequate penalties to serve as a dependable deterrent against the infringement of these precepts.

  2. Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature

    NARCIS (Netherlands)

    Simons, S.M.; Cillessen, F.H.J.M.; Hazelzet, J.A.

    2016-01-01

    BACKGROUND: A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing

  3. Effectiveness of Revised Pharmacology Record Books as a Teaching-Learning Method for Second Year Medical Students

    Science.gov (United States)

    Gangadhar, Reneega

    2016-01-01

    Introduction The goal of teaching medical undergraduates Pharmacology is to form a sound foundation of therapeutics. The pharmacology record books are maintained as a part of the curriculum. The purpose of this study was to obtain feedback of the medical students about the new record adopted in the institution after major revision Materials and Methods This was a questionnaire based study done in a Government Medical College of Kerala in February 2013. The data was analysed using SPSS. The feedback on clinical pharmacology exercises was given positive and negative scores. Results Majority (64.5%) opined that the content in pharmacology record was good. A total of 78.1% completed the record during discussions in practical classes. Majority wrote the records for understanding pharmacology. For 79.8% General Pharmacology exercises were most relevant, 33.8% considered Clinical Pharmacology exercises to be the most thought provoking. Drug use in special groups received the maximum positive score. Conclusion The new improved pharmacology record is an effective teaching-learning method. Inclusion of more clinically oriented exercises has increased the interest of the students in the subject. PMID:26894083

  4. Epidemic surveillance using an electronic medical record: an empiric approach to performance improvement.

    Directory of Open Access Journals (Sweden)

    Hongzhang Zheng

    Full Text Available BACKGROUNDS: Electronic medical records (EMR form a rich repository of information that could benefit public health. We asked how structured and free-text narrative EMR data should be combined to improve epidemic surveillance for acute respiratory infections (ARI. METHODS: Eight previously characterized ARI case detection algorithms (CDA were applied to historical EMR entries to create authentic time series of daily ARI case counts (background. An epidemic model simulated influenza cases (injection. From the time of the injection, cluster-detection statistics were applied daily on paired background+injection (combined and background-only time series. This cycle was then repeated with the injection shifted to each week of the evaluation year. We computed: a the time from injection to the first statistical alarm uniquely found in the combined dataset (Detection Delay; b how often alarms originated in the background-only dataset (false-alarm rate, or FAR; and c the number of cases found within these false alarms (Caseload. For each CDA, we plotted the Detection Delay as a function of FAR or Caseload, over a broad range of alarm thresholds. RESULTS: CDAs that combined text analyses seeking ARI symptoms in clinical notes with provider-assigned diagnostic codes in order to maximize the precision rather than the sensitivity of case-detection lowered Detection Delay at any given FAR or Caseload. CONCLUSION: An empiric approach can guide the integration of EMR data into case-detection methods that improve both the timeliness and efficiency of epidemic detection.

  5. Knowledge retrieval from PubMed abstracts and electronic medical records with the Multiple Sclerosis Ontology.

    Science.gov (United States)

    Malhotra, Ashutosh; Gündel, Michaela; Rajput, Abdul Mateen; Mevissen, Heinz-Theodor; Saiz, Albert; Pastor, Xavier; Lozano-Rubi, Raimundo; Martinez-Lapiscina, Elena H; Martinez-Lapsicina, Elena H; Zubizarreta, Irati; Mueller, Bernd; Kotelnikova, Ekaterina; Toldo, Luca; Hofmann-Apitius, Martin; Villoslada, Pablo

    2015-01-01

    In order to retrieve useful information from scientific literature and electronic medical records (EMR) we developed an ontology specific for Multiple Sclerosis (MS). The MS Ontology was created using scientific literature and expert review under the Protégé OWL environment. We developed a dictionary with semantic synonyms and translations to different languages for mining EMR. The MS Ontology was integrated with other ontologies and dictionaries (diseases/comorbidities, gene/protein, pathways, drug) into the text-mining tool SCAIView. We analyzed the EMRs from 624 patients with MS using the MS ontology dictionary in order to identify drug usage and comorbidities in MS. Testing competency questions and functional evaluation using F statistics further validated the usefulness of MS ontology. Validation of the lexicalized ontology by means of named entity recognition-based methods showed an adequate performance (F score = 0.73). The MS Ontology retrieved 80% of the genes associated with MS from scientific abstracts and identified additional pathways targeted by approved disease-modifying drugs (e.g. apoptosis pathways associated with mitoxantrone, rituximab and fingolimod). The analysis of the EMR from patients with MS identified current usage of disease modifying drugs and symptomatic therapy as well as comorbidities, which are in agreement with recent reports. The MS Ontology provides a semantic framework that is able to automatically extract information from both scientific literature and EMR from patients with MS, revealing new pathogenesis insights as well as new clinical information.

  6. Reducing Clinical Trial Monitoring Resource Allocation and Costs Through Remote Access to Electronic Medical Records

    Science.gov (United States)

    Uren, Shannon C.; Kirkman, Mitchell B.; Dalton, Brad S.; Zalcberg, John R.

    2013-01-01

    Purpose: With electronic medical records (eMRs), the option now exists for clinical trial monitors to perform source data verification (SDV) remotely. We report on a feasibility study of remote access to eMRs for SDV and the potential advantages of such a process in terms of resource allocation and cost. Methods: The Clinical Trials Unit at the Peter MacCallum Cancer Centre, in collaboration with Novartis Pharmaceuticals Australia, conducted a 6-month feasibility study of remote SDV. A Novartis monitor was granted dedicated software and restricted remote access to the eMR portal of the cancer center, thereby providing an avenue through which perform SDV. Results: Six monitoring visits were conducted during the study period, four of which were performed remotely. The ability to conduct two thirds of the monitoring visits remotely in this complex phase III study resulted in an overall cost saving to Novartis. Similarly, remote monitoring eased the strain on internal resources, particularly monitoring space and hospital computer terminal access, at the cancer center. Conclusion: Remote access to patient eMRs for SDV is feasible and is potentially an avenue through which resources can be more efficiently used. Although this feasibility study involved limited numbers, there is no limit to scaling these processes to any number of patients enrolled onto large clinical trials. PMID:23633977

  7. Electronic Surveillance of Testicular Cancer: Understanding Patient Perspectives on Access to Electronic Medical Records

    Science.gov (United States)

    Groll, Ryan J.; Leonard, Kevin J.; Eakin, Joan; Warde, Padraig; Bender, Jackie; Jewett, Michael A.S.

    2009-01-01

    Purpose: To understand patient perceptions and attitudes regarding online access to testicular cancer surveillance test results, and to identify factors that may be important in maximizing referencing of electronic medical records (EMRs) by patients for these results. Methods: In this qualitative study, seven focus groups were conducted with a total of 22 patients undergoing surveillance for testicular cancer. Transcript data were analyzed iteratively using combined manual and computerized coding by two independent coders to generate a theoretic framework grounded in the data. Results: Practicality, meaning of information, patient-physician relationship, risk of recurrence, and role of technology were identified as interrelated factors that frame how patients regard potential surveillance technology. The influence of each factor hinged on its relationship with reassurance—the central predominant factor. Additionally, time since start of surveillance seemed to affect the relative importance of all other factors. Conclusion: Prevailing models of technology acceptance understate the complexity of the situation of the patient user and the implications of online access to health information. Surveillance for testicular cancer seems to be a suitable context for patient access to EMR information if patient perspectives are to be understood and considered. Reassurance is the overriding element influencing attitudes. PMID:20856632

  8. Electronic medical record systems in critical access hospitals: leadership perspectives on anticipated and realized benefits.

    Science.gov (United States)

    Mills, Troy R; Vavroch, Jared; Bahensky, James A; Ward, Marcia M

    2010-04-01

    The growth of electronic medical records (EMRs) is driven by the belief that EMRs will significantly improve healthcare providers' performance and reduce healthcare costs. Evidence supporting these beliefs is limited, especially for small rural hospitals. A survey that focused on health information technology (HIT) capacity was administered to all hospitals in Iowa. Structured interviews were conducted with the leadership at 15 critical access hospitals (CAHs) that had implemented EMRs in order to assess the perceived benefits of operational EMRs. The results indicate that most of the hospitals implemented EMRs to improve efficiency, timely access, and quality. Many CAH leaders also viewed EMR implementation as a necessary business strategy to remain viable and improve financial performance. While some reasons reflect external influences, such as perceived future federal mandates, other reasons suggest that the decision was driven by internal forces, including the hospital's culture and the desires of key leaders to embrace HIT. Anticipated benefits were consistent with goals; however, realized benefits were rarely obvious in terms of quantifiable results. These findings expand the limited research on the rationale for implementing EMRs in critical access hospitals.

  9. [Injuries treated in primary care in the Community of Madrid: analyses of electronic medical records].

    Science.gov (United States)

    Zoni, Ana Clara; Domínguez-Berjón, María Felicitas; Esteban-Vasallo, María Dolores; Regidor, Enrique

    2014-01-01

    To describe the incidence of injuries treated in primary care by type of injury, age groups, and sex in the publicly-funded health system of the region of Madrid in Spain. A descriptive cross sectional study was performed of injury episodes registered in the primary care electronic medical records of the health system of Madrid in 2011. We calculated the global incidence of injuries, injury-specific rates for fractures, sprains, wounds, burns, foreign body injuries, poisoning and bruises, and their rate ratios with 95% confidence intervals, all of which were stratified by sex and age groups. In 2011 there were 707,800 injury episodes (3.5% of all episodes treated in primary care). Most of the injuries occurred in women (54.0%) and in persons older than 34 years (58.0%). The most common injuries were wounds in men (35.3%) and bruises in women (30.6%). Overall, women had higher rates of injuries among the elderly and men had more injuries in the group younger than 15 years. By type of injury, the highest rates of fractures, burns and bruises were observed in the older population, foreign body injuries and wounds in children, sprains in youth, and poisonings in extreme ages. The special vulnerability of boys younger than 5 years and elderly women suggests that intervention strategies should be targeted to the specific needs of these groups. Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.

  10. Building a diabetes screening population data repository using electronic medical records.

    Science.gov (United States)

    Tuan, Wen-Jan; Sheehy, Ann M; Smith, Maureen A

    2011-05-01

    There has been a rapid advancement of information technology in the area of clinical and population health data management since 2000. However, with the fast growth of electronic medical records (EMRs) and the increasing complexity of information systems, it has become challenging for researchers to effectively access, locate, extract, and analyze information critical to their research. This article introduces an outpatient encounter data framework designed to construct an EMR-based population data repository for diabetes screening research. The outpatient encounter data framework is developed on a hybrid data structure of entity-attribute-value models, dimensional models, and relational models. This design preserves a small number of subject-specific tables essential to key clinical constructs in the data repository. It enables atomic information to be maintained in a transparent and meaningful way to researchers and health care practitioners who need to access data and still achieve the same performance level as conventional data warehouse models. A six-layer information processing strategy is developed to extract and transform EMRs to the research data repository. The data structure also complies with both Health Insurance Portability and Accountability Act regulations and the institutional review board's requirements. Although developed for diabetes screening research, the design of the outpatient encounter data framework is suitable for other types of health service research. It may also provide organizations a tool to improve health care quality and efficiency, consistent with the "meaningful use" objectives of the Health Information Technology for Economic and Clinical Health Act.

  11. Restructuring the electronic medical record to incorporate full digital signature capability.

    Science.gov (United States)

    Zuckerman, A E

    2001-01-01

    The security of Electronic Medical Records can be enhanced by the addition of digital signatures that guarantee data integrity, authenticate the signer, and establish non-repudiation through the use of public key encryption. The task is complicated by the contribution of multiple providers to an encounter and the entry of data at multiple points in time Dividing encounters into an episode of care and redesigning the data model of the EMR will facilitate full signature capabilities. Generation of digital signatures is best accomplished using microprocessors on smart cards that control visibility of the private keys and assist in user authentication. The Java Programming Language including cryptography extensions and a smart card API is a useful tool for adding digital signature to an EMR. Inter-operability of signatures and continuity of signature will require attention to standards and preservation of cryptography and authentication certificate archives. Digital signatures will need to accommodate changes in data storage formats when information is transported between EMR systems using XML or other transaction standards because the original signatures will not validate if the data storage format changes. The costs of adding digital signature to EMR mandates serious examination of the business case for digital signature within an EMR as compared with transactions such as electronic prescriptions. At present, there is no regulatory requirement for digital signature of an EMR.

  12. Automating Quality Metrics in the Era of Electronic Medical Records: Digital Signatures for Ventilator Bundle Compliance.

    Science.gov (United States)

    Lan, Haitao; Thongprayoon, Charat; Ahmed, Adil; Herasevich, Vitaly; Sampathkumar, Priya; Gajic, Ognjen; O'Horo, John C

    2015-01-01

    Ventilator-associated events (VAEs) are associated with increased risk of poor outcomes, including death. Bundle practices including thromboembolism prophylaxis, stress ulcer prophylaxis, oral care, and daily sedation breaks and spontaneous breathing trials aim to reduce rates of VAEs and are endorsed as quality metrics in the intensive care units. We sought to create electronic search algorithms (digital signatures) to evaluate compliance with ventilator bundle components as the first step in a larger project evaluating the ventilator bundle effect on VAE. We developed digital signatures of bundle compliance using a retrospective cohort of 542 ICU patients from 2010 for derivation and validation and testing of signature accuracy from a cohort of random 100 patients from 2012. Accuracy was evaluated against manual chart review. Overall, digital signatures performed well, with median sensitivity of 100% (range, 94.4%-100%) and median specificity of 100% (range, 100%-99.8%). Automated ascertainment from electronic medical records accurately assesses ventilator bundle compliance and can be used for quality reporting and research in VAE.

  13. The medical ethics of Dr J Marion Sims: a fresh look at the historical record.

    Science.gov (United States)

    Wall, L L

    2006-06-01

    Vesicovaginal fistula was a catastrophic complication of childbirth among 19th century American women. The first consistently successful operation for this condition was developed by Dr J Marion Sims, an Alabama surgeon who carried out a series of experimental operations on black slave women between 1845 and 1849. Numerous modern authors have attacked Sims's medical ethics, arguing that he manipulated the institution of slavery to perform ethically unacceptable human experiments on powerless, unconsenting women. This article reviews these allegations using primary historical source material and concludes that the charges that have been made against Sims are largely without merit. Sims's modern critics have discounted the enormous suffering experienced by fistula victims, have ignored the controversies that surrounded the introduction of anaesthesia into surgical practice in the middle of the 19th century, and have consistently misrepresented the historical record in their attacks on Sims. Although enslaved African American women certainly represented a "vulnerable population" in the 19th century American South, the evidence suggests that Sims's original patients were willing participants in his surgical attempts to cure their affliction-a condition for which no other viable therapy existed at that time.

  14. Automated Detection of Sepsis Using Electronic Medical Record Data: A Systematic Review.

    Science.gov (United States)

    Despins, Laurel A

    2016-09-13

    Severe sepsis and septic shock are global issues with high mortality rates. Early recognition and intervention are essential to optimize patient outcomes. Automated detection using electronic medical record (EMR) data can assist this process. This review describes automated sepsis detection using EMR data. PubMed retrieved publications between January 1, 2005 and January 31, 2015. Thirteen studies met study criteria: described an automated detection approach with the potential to detect sepsis or sepsis-related deterioration in real or near-real time; focused on emergency department and hospitalized neonatal, pediatric, or adult patients; and provided performance measures or results indicating the impact of automated sepsis detection. Detection algorithms incorporated systemic inflammatory response and organ dysfunction criteria. Systems in nine studies generated study or care team alerts. Care team alerts did not consistently lead to earlier interventions. Earlier interventions did not consistently translate to improved patient outcomes. Performance measures were inconsistent. Automated sepsis detection is potentially a means to enable early sepsis-related therapy but current performance variability highlights the need for further research.

  15. Effect of an electronic medical record alert for severe sepsis among ED patients.

    Science.gov (United States)

    Narayanan, Navaneeth; Gross, A Kendall; Pintens, Megan; Fee, Christopher; MacDougall, Conan

    2016-02-01

    Severe sepsis and septic shock are a major health concern worldwide. The objective of this study is to determine if Severe Sepsis Best Practice Alert (SS-BPA) implementation was associated with improved processes of care and clinical outcomes among patients with severe sepsis or septic shock presenting to the emergency department (ED). This is a single-center, before-and-after observational study. The intervention group (n = 103) consisted of adult patients presenting to the ED with severe sepsis or septic shock during a 7-month period after implementation of the SS-BPA. The control group (n = 111) consisted of patients meeting the same criteria over a prior 7-month period. The SS-BPA primarily acts by automated, real-time, algorithm-based detection of severe sepsis or septic shock via the electronic medical record system. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (LOS), time to antibiotic administration, and proportion of patients who received antibiotics within the target 60 minutes. Time to antibiotics was significantly reduced in the SS-BPA cohort (29 vs 61.5 minutes, P sepsis or septic shock among ED patients is associated with significantly improved timeliness of antibiotic administration and reduced hospital LOS. Copyright © 2015 Elsevier Inc. All rights reserved.

  16. Using the Deming quality improvement method to manage medical record department product lines.

    Science.gov (United States)

    Postal, S N

    1990-06-01

    The above application of the quality improvement cycle provides insight into the use of the Deming method to address one of several identified customer needs and expectations obtained during the managing phase of product-line administration. Implementation of the quality improvement method requires a major commitment from all team members. Process improvement requires a willingness to be detail oriented. Gathering of statistics--such as analysis turn-around time--and evaluation are critical. This objective view of processes requires accountability and a commitment to change. Improvements focus on long-term problem resolution, not the quick fixes that result from addressing symptoms of problems. True problem resolution occurs by solving the root causes of variations. Medical record departments must move from being outcome oriented to being process focused. It is no longer feasible to be constantly putting out fires in an environment that demands well-planned and well-designed products that meet customers' expectations. The long-term management of product lines requires a systematic method of planning, doing, checking, and acting. The Deming quality improvement method provides a framework for positive change that focuses on quality processes resulting in a quality product that meets consumers' needs.

  17. [The estimation of penetrating of microbes by the protective clothing and textile medical devices, according to obligatory norms].

    Science.gov (United States)

    Zareba, Tomasz; Zych, Magdalena; Kruszewska, Hanna; Mrówka, Agnieszka; Wasińska, Ewa; Tyski, Stefan

    2010-01-01

    Textile medical products can be widely used as barrier materials and individual protection against biological threats. Rules of introducing such products to market are regulated by the Directive 93/42/ EEC. Detailed requirements and testing methods of textile medical products are presented in obligatory norms. The required level of protection of these products against the penetration of microbes depends on the risk connected with planned type surgical procedure, the duration of the surgical intervention, risks of bleeding or presences of other body liquids of the patient and susceptibilities of the patient to infection. The aim of the study was to establish resistance of medical textiles to wet bacterial penetration. Materials were examined by the apparatus dedicated to this type of testing and obtained results were rated with reference to obligatory contracted requirements. assured Textiles laminated with foils possessed best protective proprieties, whereas medical products made from the cotton do not provide the sufficient level of the protection against microbes.

  18. Development of a peer review system using patient records for outcome evaluation of medical education: reliability analysis.

    Science.gov (United States)

    Kameoka, Junichi; Okubo, Tomoya; Koguma, Emi; Takahashi, Fumie; Ishii, Seiichi; Kanatsuka, Hiroshi

    2014-01-01

    In addition to input evaluation (education delivered at school) and output evaluation (students' capability at graduation), the methods for outcome evaluation (performance after graduation) of medical education need to be established. One approach is a review of medical records, which, however, has been met with difficulties because of poor inter-rater reliability. Here, we attempted to develop a peer review system of medical records with high inter-rater reliability. We randomly selected 112 patients (and finally selected 110 after removing two ineligible patients) who visited (and were hospitalized in) one of the four general hospitals in the Tohoku region of Japan between 2008 and 2012. Four reviewers, who were well-trained general internists from outside the Tohoku region, visited the hospitals independently and evaluated outpatient medical records based on an evaluation sheet that consisted of 14 items (3-point scale) for record keeping and 15 items (5-point scale) for quality of care. The mean total score was 84.1 ± 7.7. Cronbach's alpha for these items was 0.798. Single measure and average measure intraclass correlations for the reviewers were 0.733 (95% confidence interval: 0.720-0.745) and 0.917 (95% confidence interval: 0.912-0.921), respectively. An exploratory factor analysis revealed six factors: history taking, physical examination, clinical reasoning, management and outcome, rhetoric, and patient relationship. In conclusion, we have developed a peer review system of medical records with high inter-rater reliability, which may enable us, with further validity analysis, to measure quality of patient care as an outcome evaluation of medical education in the future.

  19. Annotation methods to develop and evaluate an expert system based on natural language processing in electronic medical records.

    Science.gov (United States)

    Gicquel, Quentin; Tvardik, Nastassia; Bouvry, Côme; Kergourlay, Ivan; Bittar, André; Segond, Frédérique; Darmoni, Stefan; Metzger, Marie-Hélène

    2015-01-01

    The objective of the SYNODOS collaborative project was to develop a generic IT solution, combining a medical terminology server, a semantic analyser and a knowledge base. The goal of the project was to generate meaningful epidemiological data for various medical domains from the textual content of French medical records. In the context of this project, we built a care pathway oriented conceptual model and corresponding annotation method to develop and evaluate an expert system's knowledge base. The annotation method is based on a semi-automatic process, using a software application (MedIndex). This application exchanges with a cross-lingual multi-termino-ontology portal. The annotator selects the most appropriate medical code proposed for the medical concept in question by the multi-termino-ontology portal and temporally labels the medical concept according to the course of the medical event. This choice of conceptual model and annotation method aims to create a generic database of facts for the secondary use of electronic health records data.

  20. 病案管理中存在的医患纠纷隐患与改进策略%Doctor-patient Potential Dispute Existing in Medical Record Management and Improvement Measures

    Institute of Scientific and Technical Information of China (English)

    殷岳

    2016-01-01

    Aimed at the current situations that doctor-patient disputes frequently happened, scope expanding gradually and affairs severity upgrading, this paper focused on the influence of medical record quality and medical record management on the medical disputes, to improve the overall level of medical documents, improve the quality of medical record related services, avoid the medical disputes caused by medical record management and protect the legitimate rights and interests of both doctors and patients. The article analyzed on the potential dispute in medical record management separately from five aspects, such as medical record writing quality, medical record management transparency, informatization, security and humanization. Combined with the problems existing in the current management work, and its effect in the production and processing of medical disputes, we put forward the improving countermeasures according to the existing problems, such as enhancing the quality of medical documents regulation, and making feasible policy guarantee that medical staff had enough time and energy to improve the medical records. To external circumstance, we should increase the transparency of medical record, strengthen the medical record management informatization construction, prevent the disclosure of medical record information, protect the privacy of patients and strengthen the humanized service from the perspective of the patient and family.%针对当前医患纠纷事件频发,范围逐渐扩大、严重程度升级的情况,着眼于病案质量及病案管理对医患纠纷的影响,旨在提高医疗文书的整体水平,提升病案相关的服务质量,规避因病案管理不善所引发的医患纠纷,保护医患双方的合法权益.病案管理存在的隐患分别从病案书写质量、病案管理透明化、信息化、安全性及人性化等五个方面分析.结合当前存在的问题在医患纠纷的产生和处理中的影响,提出以下改进对策:增

  1. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions

    Directory of Open Access Journals (Sweden)

    Broekhuis Manda

    2010-08-01

    Full Text Available Abstract Background The main objective of this research is to identify, categorize, and analyze barriers perceived by physicians to the adoption of Electronic Medical Records (EMRs in order to provide implementers with beneficial intervention options. Methods A systematic literature review, based on research papers from 1998 to 2009, concerning barriers to the acceptance of EMRs by physicians was conducted. Four databases, "Science", "EBSCO", "PubMed" and "The Cochrane Library", were used in the literature search. Studies were included in the analysis if they reported on physicians' perceived barriers to implementing and using electronic medical records. Electronic medical records are defined as computerized medical information systems that collect, store and display patient information. Results The study includes twenty-two articles that have considered barriers to EMR as perceived by physicians. Eight main categories of barriers, including a total of 31 sub-categories, were identified. These eight categories are: A Financial, B Technical, C Time, D Psychological, E Social, F Legal, G Organizational, and H Change Process. All these categories are interrelated with each other. In particular, Categories G (Organizational and H (Change Process seem to be mediating factors on other barriers. By adopting a change management perspective, we develop some barrier-related interventions that could overcome the identified barriers. Conclusions Despite the positive effects of EMR usage in medical practices, the adoption rate of such systems is still low and meets resistance from physicians. This systematic review reveals that physicians may face a range of barriers when they approach EMR implementation. We conclude that the process of EMR implementation should be treated as a change project, and led by implementers or change managers, in medical practices. The quality of change management plays an important role in the success of EMR implementation. The

  2. Quantum Digital Signatures for Unconditional Safe Authenticity Protection of Medical Documentation

    Directory of Open Access Journals (Sweden)

    Arkadiusz Liber

    2015-12-01

    Full Text Available Modern medical documentation appears most often in an online form which requires some digital methods to ensure its confidentiality, integrity and authenticity. The document authenticity may be secured with the use of a signature. A classical handwritten signature is directly related to its owner by his/her psychomotor character traits. Such a signature is also connected with the material it is written on, and a writing tool. Because of these properties, a handwritten signature reflects certain close material bonds between the owner and the document. In case of modern digital signatures, the document authentication has a mathematical nature. The verification of the authenticity becomes the verification of a key instead of a human. Since 1994 it has been known that classical digital signature algorithms may not be safe because of the Shor’s factorization algorithm. To implement the modern authenticity protection of medical data, some new types of algorithms should be used. One of the groups of such algorithms is based on the quantum computations. In this paper, the analysis of the current knowledge status of Quantum Digital Signature protocols, with its basic principles, phases and common elements such as transmission, comparison and encryption, was outlined. Some of the most promising protocols for signing digital medical documentation, that fulfill the requirements for QDS, were also briefly described. We showed that, a QDS protocol with QKD components requires the equipment similar to the equipment used for a QKD, for its implementation, which is already commercially available. If it is properly implemented, it provides the shortest lifetime of qubits in comparison to other protocols. It can be used not only to sign classical messages but probably it could be well adopted to implement unconditionally safe protection of medical documentation in the nearest future, as well.

  3. 口腔颌面外科住院病案质量存在的问题及思考%Problems and Reflection of Inpatient Medical Record Quality in Oral and Maxillofacial Surgery

    Institute of Scientific and Technical Information of China (English)

    喻棣; 曾大顺; 金凯; 李小新; 陈剑云

    2016-01-01

    Objective By randomly checking inpatient medical record in oral and maxillofacial surgery and analyzing the existing quality problems in medical record, put forward corresponding countermeasures for medical record quality management so as to improve inpatient medical record in oral and maxillofacial surgery.Methods 500 cases of inpatient medical records in oral and maxillofacial surgery from 2013-2014 were checked and the problems in medical record quality and their causes were analyzed before relevant suggestions were put forward.Results The main problems of inpatient medical records in oral and maxillofacial surgery included: delayed record, unrelated or undetailed content, deficiency, the lack of systematic and scientific medical history, the lack of pertinence, indistinct definition for discharge and the lack of signature.Conclusion Inpatient medical record in oral and maxillofacial surgery has certain problems, which could be improved through improving medical record writing ability, strengthening medical record quality consciousness, strengthening control, improving and implementing relevant policies.

  4. Longitudinal Prescribing Patterns for Psychoactive Medications in Community-Based Individuals with Developmental Disabilities: Utilization of Pharmacy Records

    Science.gov (United States)

    Lott, I. T.; McGregor, M.; Engelman, L.; Touchette, P.; Tournay, A.; Sandman, C.; Fernandez, G.; Plon, L.; Walsh, D.

    2004-01-01

    Little is known about longitudinal prescribing practices for psychoactive medications for individuals with intellectual disabilities and developmental disabilities (IDDD) who are living in community settings. Computerized pharmacy records were accessed for 2344 community-based individuals with IDDD for whom a total of 3421 prescriptions were…

  5. The Study of Electronic Medical Record Adoption in a Medicare Certified Home Health Agency Using a Grounded Theory Approach

    Science.gov (United States)

    May, Joy L.

    2013-01-01

    The purpose of this qualitative grounded theory study was to examine the experiences of clinicians in the adoption of Electronic Medical Records in a Medicare certified Home Health Agency. An additional goal for this study was to triangulate qualitative research between describing, explaining, and exploring technology acceptance. The experiences…

  6. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions

    NARCIS (Netherlands)

    Boonstra, Albert; Broekhuis, Manda

    2010-01-01

    Background: The main objective of this research is to identify, categorize, and analyze barriers perceived by physicians to the adoption of Electronic Medical Records (EMRs) in order to provide implementers with beneficial intervention options. Methods: A systematic literature review, based on resea

  7. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions

    NARCIS (Netherlands)

    Boonstra, Albert; Broekhuis, Manda

    2010-01-01

    Background: The main objective of this research is to identify, categorize, and analyze barriers perceived by physicians to the adoption of Electronic Medical Records (EMRs) in order to provide implementers with beneficial intervention options. Methods: A systematic literature review, based on

  8. The comparison of cardiovascular risk scores using two methods of substituting missing risk factor data in patient medical records

    Directory of Open Access Journals (Sweden)

    Andrew Dalton

    2011-07-01

    Conclusions A simple method of substituting missing risk factor data can produce reliable estimates of CVD risk scores. Targeted screening for high CVD risk, using pre-existing electronic medical record data, does not require multiple imputation methods in risk estimation.

  9. Giving rheumatology patients online home access to their electronic medical record (EMR): advantages, drawbacks and preconditions according to care providers

    NARCIS (Netherlands)

    Vaart, van der R.; Drossaert, C.H.C.; Taal, E.; Laar, van de M.A.F.J.

    2013-01-01

    Technology enables patients home access to their electronic medical record (EMR), via a patient portal. This study aims to analyse (dis)advantages, preconditions and suitable content for this service, according to rheumatology health professionals. A two-phase policy Delphi study was conducted. Firs

  10. The HEAL, Phase II Project: enhancing features of an electronic medical record system to improve adherence to asthma guidelines.

    Science.gov (United States)

    Rapp, Kristi Isaac; Jack, Leonard; Post, Robert; Flores, Jose; Morris, Nancy; Arnaud, Roslyn; Malveaux, Floyd; Woodall-Ruff, Denise; Sanders, Margaret; Denham, Stacey; Sunda-Meya, Doryne; Wilson, Candice

    2013-02-01

    This article describes the implementation of an enhanced electronic medical record (EMR) system in three community health care centers in the Greater New Orleans area of Louisiana. This report may aid efforts directed at the implementation of enriched tools, such as decision support, in an EMR with the goal of improving pediatric asthma outcomes.

  11. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions

    NARCIS (Netherlands)

    Boonstra, Albert; Broekhuis, Manda

    2010-01-01

    Background: The main objective of this research is to identify, categorize, and analyze barriers perceived by physicians to the adoption of Electronic Medical Records (EMRs) in order to provide implementers with beneficial intervention options. Methods: A systematic literature review, based on resea

  12. Electronic Medical Records (EMR): An Empirical Testing of Factors Contributing to Healthcare Professionals' Resistance to Use EMR Systems

    Science.gov (United States)

    Bazile, Emmanuel Patrick

    2016-01-01

    The benefits of using electronic medical records (EMRs) have been well documented; however, despite numerous financial benefits and cost reductions being offered by the federal government, some healthcare professionals have been reluctant to implement EMR systems. In fact, prior research provides evidence of failed EMR implementations due to…

  13. Reusability of coded data in the primary care electronic medical record : A dynamic cohort study concerning cancer diagnoses

    NARCIS (Netherlands)

    Sollie, Annet; Sijmons, Rolf H.; Helsper, Charles W.; Numans, Mattijs E.

    2017-01-01

    Objectives: To assess quality and reusability of coded cancer diagnoses in routine primary care data. To identify factors that influence data quality and areas for improvement. Methods: A dynamic cohort study in a Dutch network database containing 250,000 anonymized electronic medical records (EMRs)

  14. Reusability of coded data in the primary care electronic medical record : A dynamic cohort study concerning cancer diagnoses

    NARCIS (Netherlands)

    Sollie, Annet; Sijmons, Rolf H; Helsper, Charles; Numans, Mattijs E

    2017-01-01

    OBJECTIVES: To assess quality and reusability of coded cancer diagnoses in routine primary care data. To identify factors that influence data quality and areas for improvement. METHODS: A dynamic cohort study in a Dutch network database containing 250,000 anonymized electronic medical records (EMRs)

  15. The requirements of the Data Protection Act 1998 for the processing of medical data.

    Science.gov (United States)

    Boyd, P

    2003-02-01

    The Data Protection Act 1998 presents a number of significant challenges to data controllers in the health sector. To assist data controllers in understanding their obligations under the act, the Information Commissioner has published guidance, The Use and Disclosure of Health Data, which is reproduced here. The guidance deals, among other things, with the steps that must be taken to obtain patient data fairly, the implied requirements of the act to use anonymised or psuedonymised data where possible, an exemption applicable principally to records based research, the right of patients to object to the processing of their data, and the interface of the act and the common law duty of confidence.

  16. Prevalence and usage of printed and electronic drug references and patient medication records in community pharmacies in Malaysia.

    Science.gov (United States)

    Usir, Ezlina; Lua, Pei Lin; Majeed, Abu Bakar Abdul

    2012-06-01

    This study aimed to determine the availability and usage of printed and electronic references and Patient Medication Record in community pharmacy. It was conducted for over 3 months from 15 January to 30 April 2007. Ninety-three pharmacies participated. Structured questionnaires were mailed to community pharmacies. Six weeks later a reminder was sent to all non responders, who were given another six weeks to return the completed questionnaire. Outcomes were analyzed using descriptive statistics and chi-square test of independence. Almost all the pharmacies (96.8%) have at least Monthly Index of Medical Specialties (MIMS) while 78.5% have at least MIMS ANNUAL in their stores. Only about a third (31.2%) of the pharmacies were equipped with online facilities of which the majority referred to medical websites (88.9%) with only a minority (11.1%) referring to electronic journals. More than half (59.1%) of the pharmacists kept Patient Medication Record profiles with 49.1% storing it in paper, 41.8% electronically and 9.1% in both printed and electronic versions. In general, prevalence and usage of electronic references in community pharmacies were rather low. Efforts should be increased to encourage wider usage of electronic references and Patient Medication Records in community pharmacies to facilitate pharmaceutical care.

  17. An Efficient Searchable Encryption Against Keyword Guessing Attacks for Sharable Electronic Medical Records in Cloud-based System.

    Science.gov (United States)

    Wu, Yilun; Lu, Xicheng; Su, Jinshu; Chen, Peixin

    2016-12-01

    Preserving the privacy of electronic medical records (EMRs) is extremely important especially when medical systems adopt cloud services to store patients' electronic medical records. Considering both the privacy and the utilization of EMRs, some medical systems apply searchable encryption to encrypt EMRs and enable authorized users to search over these encrypted records. Since individuals would like to share their EMRs with multiple persons, how to design an efficient searchable encryption for sharable EMRs is still a very challenge work. In this paper, we propose a cost-efficient secure channel free searchable encryption (SCF-PEKS) scheme for sharable EMRs. Comparing with existing SCF-PEKS solutions, our scheme reduces the storage overhead and achieves better computation performance. Moreover, our scheme can guard against keyword guessing attack, which is neglected by most of the existing schemes. Finally, we implement both our scheme and a latest medical-based scheme to evaluate the performance. The evaluation results show that our scheme performs much better performance than the latest one for sharable EMRs.

  18. Design and implementation of a web-based patient portal linked to an electronic health record designed to improve medication safety: the Patient Gateway medications module

    Directory of Open Access Journals (Sweden)

    Jeffrey Schnipper

    2008-07-01

    Full Text Available In this article we describe the background, design, and preliminary results of a medications module within Patient Gateway (PG, a patient portal linked to an electronic health record (EHR. The medications module is designed to improve the accuracy of medication lists within the EHR, reduce adverse drug events and improve patient_provider communication regarding medications and allergies in several primary care practices within a large integrated healthcare delivery network. This module allows patients to view and modify the list of medications and allergies from the EHR, report nonadherence, side effects and other medication-related problems and easily communicate this information to providers, who can verify the information and update the EHR as needed. Usage and satisfaction data indicate that patients found the module easy to use, felt that it led to their providers having more accurate information about them and enabled them to feel more prepared for their forthcoming visits. Further analyses will determine the effects of this module on important medication-related outcomes and identify further enhancements needed to improve on this approach.

  19. Bringing science to medicine: an interview with Larry Weed, inventor of the problem-oriented medical record.

    Science.gov (United States)

    Wright, Adam; Sittig, Dean F; McGowan, Julie; Ash, Joan S; Weed, Lawrence L

    2014-01-01

    Larry Weed, MD is widely known as the father of the problem-oriented medical record and inventor of the now-ubiquitous SOAP (subjective/objective/assessment/plan) note, for developing an electronic health record system (Problem-Oriented Medical Information System, PROMIS), and for founding a company (since acquired), which developed problem-knowledge couplers. However, Dr Weed's vision for medicine goes far beyond software--over the course of his storied career, he has relentlessly sought to bring the scientific method to medical practice and, where necessary, to point out shortcomings in the system and advocate for change. In this oral history, Dr Weed describes, in his own words, the arcs of his long career and the work that remains to be done. 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.

  20. Prevention of blindness from glaucoma using the King's College Hospital computerized problem orientated medical record.

    Science.gov (United States)

    Crick, R P

    1975-04-01

    (1) Chronic glaucoma accounts for a high proportion of blindness which is preventable and calls for energetic action because existing knowledge is not applied as it should be because of the indifference of the Department of Health and Social Security to the glaucoma problem. (2) The condition is frequently insidious and advanced before being identified, and requires life-long supervision. (3) When diagnosed, the management of glaucoma is frequently inadequate and intermittent for a variety of reasons. (4) AtKing's College Hospital, a Glaucoma Centre has been initiated to supervise accurately and regularly a large number of glaucoma patients, assisted by numerical recording and computer analysis. While we are fortunate in having a computer in the hospital, it is important to emphasize that the system can be operated without this facility, either by employing manual methods, or by batch processing. It would be both possible and desirable to organize recording a nd analysis on a regional basis in collaboration with hospitals wishing to participiate. (5) Attempts are being made to improve the early diagnosis ofglaucoma by better communication between the hospital ophthalmologists, and other members of the medical, optical, and ancillary professions by lectures, demonstrations, and publications. (6) Research is always hampered by the absence of factual knowledge. It is planned to use fully the opportunity for research into glaucoma made possible by this basic organization. At present however, we consider it more important to carry out investigations into the problems of organizing the investigation, treatment, and follow-up of glaucoma patients than t o embark on a few individual projects of research. We are serously hampered in our work by shortage of funds for staff and facilities, but we look forward confidently to the time when, with the essential support of the Department of Health, these methods will give us access to the facts of glaucoma, which besides enabling

  1. Corrigendum: Big Data in medical research and EU data protection law : challenges to the consent or anonymise approach

    NARCIS (Netherlands)

    Mostert, Menno; Bredenoord, Annelien L; Biesaart, Monique C I H; van Delden, Johannes J M

    Medical research is increasingly becoming data-intensive; sensitive data are being re-used, linked and analysed on an unprecedented scale. The current EU data protection law reform has led to an intense debate about its potential effect on this processing of data in medical research. To contribute

  2. Problem Oriented Medical Record: Characterizing the Use of the Problem List at Hospital Italiano de Buenos Aires.

    Science.gov (United States)

    Franco, Mariano; Giussi Bordoni, Maria Victoria; Otero, Carlos; Landoni, Mariana Clara; Benitez, Sonia; Borbolla, Damian; Luna, Daniel

    2015-01-01

    Problem oriented medical record (POMR) was born in late sixties. Expecting an ordered, complete and updated medical record were some of the goals of its founder. Several healthcare institutions have included problem list into their clinical records but some concerns have been reported. These concerns are in reference to their voluminosity, incompleteness and outdatedness. This study attempts to understand how healthcare professionals are using the problem list at Hospital Italiano de Buenos Aires (HIBA). We believe it is essential to understand the local reality applied to our own applications and cultural instances of documentation. This report is the basis from which several improvements could be made in order to meet the goals of Weed's proposal.

  3. Evaluation of a Computerized Problem-Oriented Medical Record in a Hospital Department: Does it Support Daily Clinical Practice?

    DEFF Research Database (Denmark)

    Bossen, Claus

    2007-01-01

    led to more time spent documenting clinical work, fragmentation of patient situation into separate problems, and lack of overview.Conclusion: The problem-oriented method for structuring a computerized medical record may provide a description of how physicians think or ought to think, but does...... Purpose: Evaluation of a computerized problem-oriented medical record (CPOMR) for hospital work.Methods: A qualitative study of daily use of a CPOMR at an internal medicine hospital ward over a period of three months during which 66 patients were treated based on clinical information recorded...... in the CPOMR. The study is base on participant observation and interviews. Before and during the test period the author attended project planning meetings, a training workshop in the use of the CPOMR for nurses and physicians and local coordination meetings. After the test, 1 focus-group discussion...

  4. 75 FR 67777 - Copyright Office; Federal Copyright Protection of Sound Recordings Fixed Before February 15, 1972

    Science.gov (United States)

    2010-11-03

    ... works. The Copyright Office Study Faced with the uncertain patchwork of State laws that cover pre- 1972... is to cover the effect of federal coverage on the preservation of such sound recordings, the effect... commercial recordings encompass a wide range of genres: ragtime and jazz, rhythm and blues, gospel, country...

  5. 36 CFR 1223.22 - How must agencies protect vital records?

    Science.gov (United States)

    2010-07-01

    ... place of business. (b) Dispersal. Once records are duplicated, they must be dispersed to sites a... locations of the same agency or some other site. (c) Storage considerations. Copies of emergency operating.... Copies of legal and financial rights records may not be needed as quickly. In deciding where to store...

  6. Investigating concordance in diabetes diagnosis between primary care charts (electronic medical records and health administrative data: a retrospective cohort study

    Directory of Open Access Journals (Sweden)

    Chevendra Vijaya

    2010-12-01

    Full Text Available Abstract Background Electronic medical records contain valuable clinical information not readily available elsewhere. Accordingly, they hold important potential for contributing to and enhancing chronic disease registries with the goal of improving chronic disease management; however a standard for diagnoses of conditions such as diabetes remains to be developed. The purpose of this study was to establish a validated electronic medical record definition for diabetes. Methods We constructed a retrospective cohort using health administrative data from the Institute for Clinical Evaluative Sciences Ontario Diabetes Database linked with electronic medical records from the Deliver Primary Healthcare Information Project using data from 1 April 2006 - 31 March 2008 (N = 19,443. We systematically examined eight definitions for diabetes diagnosis, both established and proposed. Results The definition that identified the highest number of patients with diabetes (N = 2,180 while limiting to those with the highest probability of having diabetes was: individuals with ≥2 abnormal plasma glucose tests, or diabetes on the problem list, or insulin prescription, or ≥2 oral anti-diabetic agents, or HbA1c ≥6.5%. Compared to the Ontario Diabetes Database, this definition identified 13% more patients while maintaining good sensitivity (75% and specificity (98%. Conclusions This study establishes the feasibility of developing an electronic medical record standard definition of diabetes and validates an algorithm for use in this context. While the algorithm may need to be tailored to fit available data in different electronic medical records, it contributes to the establishment of validated disease registries with the goal of enhancing research, and enabling quality improvement in clinical care and patient self-management.

  7. Investigating concordance in diabetes diagnosis between primary care charts (electronic medical records) and health administrative data: a retrospective cohort study.

    Science.gov (United States)

    Harris, Stewart B; Glazier, Richard H; Tompkins, Jordan W; Wilton, Andrew S; Chevendra, Vijaya; Stewart, Moira A; Thind, Amardeep

    2010-12-23

    Electronic medical records contain valuable clinical information not readily available elsewhere. Accordingly, they hold important potential for contributing to and enhancing chronic disease registries with the goal of improving chronic disease management; however a standard for diagnoses of conditions such as diabetes remains to be developed. The purpose of this study was to establish a validated electronic medical record definition for diabetes. We constructed a retrospective cohort using health administrative data from the Institute for Clinical Evaluative Sciences Ontario Diabetes Database linked with electronic medical records from the Deliver Primary Healthcare Information Project using data from 1 April 2006-31 March 2008 (N = 19,443). We systematically examined eight definitions for diabetes diagnosis, both established and proposed. The definition that identified the highest number of patients with diabetes (N = 2,180) while limiting to those with the highest probability of having diabetes was: individuals with ≥2 abnormal plasma glucose tests, or diabetes on the problem list, or insulin prescription, or ≥2 oral anti-diabetic agents, or HbA1c ≥6.5%. Compared to the Ontario Diabetes Database, this definition identified 13% more patients while maintaining good sensitivity (75%) and specificity (98%). This study establishes the feasibility of developing an electronic medical record standard definition of diabetes and validates an algorithm for use in this context. While the algorithm may need to be tailored to fit available data in different electronic medical records, it contributes to the establishment of validated disease registries with the goal of enhancing research, and enabling quality improvement in clinical care and patient self-management.

  8. How organizational escalation prevention potential affects success of implementation of innovations: electronic medical records in hospitals.

    Science.gov (United States)

    Lambooij, Mattijs S; Koster, Ferry

    2016-05-20

    Escalation of commitment is the tendency that (innovation) projects continue, even if it is clear that they will not be successful and/or become extremely costly. Escalation prevention potential (EPP), the capability of an organization to stop or steer implementation processes that do not meet their expectations, may prevent an organization of losing time and money on unsuccessful projects. EPP consists of a set of checks and balances incorporated in managerial practices that safeguard management against irrational (but very human) decisions and may limit the escalation of implementation projects. We study whether successful implementation of electronic medical records (EMRs) relates to EPP and investigate the organizational factors accounting for this relationship. Structural equation modelling (SEM), using questionnaire data of 427 doctors and 631 nurses who had experience with implementation and use of EMRs in hospitals, was applied to study whether formal governance and organizational culture mediate the relationship between EPP and the perceived added value of EMRs. Doctors and nurses in hospitals with more EPP report more successful implementation of EMR (in terms of perceived added value of the EMR). Formal governance mediates the relation between EPP and implementation success. We found no evidence that open or innovative culture explains the relationship between EPP and implementation success. There is a positive relationship between the level of EPP and perceived added value of EMRs. This relationship is explained by formal governance mechanisms of organizations. This means that management has a set of tangible tools to positively affect the success of innovation processes. However, it also means that management needs to be able to critically reflect on its (previous) actions and decisions and is willing to change plans if elements of EPP signal that the implementation process is hampered.

  9. Assessment of performance indicators of a radiotherapy department using an electronic medical record system.

    Science.gov (United States)

    Bahadur, Yasir A; Constantinescu, Camelia; Bahadur, Ammar Y; Bahadur, Ruba Y

    2017-01-01

    To retrospectively assess the performance indicators of our radiotherapy department and their temporal trends, using a commercially available electronic-medical-record (EMR) system. A recent trend in healthcare quality is to define and evaluate performance indicators of the service provided. Patient and external-beam-radiotherapy-treatments data were retrieved using the Mosaiq EMR system from 1-January-2012 till 31-December-2015. Annual performance indicators were evaluated as: productivity (number of new cases/year and diagnosis distribution); complexity (ratio of Volumetric-Modulated-Arc-Therapy (VMAT) courses, average number of imaging procedures/patient); and quality (average, median and 90th percentile waiting times from admission to first treatment). The temporal trends of all performance indicators were assessed by linear regression. Productivity: the number of new cases/year increased with an average rate of 4%. Diagnosis distribution showed that breast is the main pathology treated, followed by gastro-intestinal and head-and-neck. Complexity: the ratio of VMAT courses increased from 13% to 35%, with an average rate of 7% per year. The average number of imaging procedures/patient increased from 8 to 11. Quality: the waiting times from admission to treatment remained stable over time (R(2) ≤ 0.1), with average, median and 90th percentile values around 20, 15, and 31 days, respectively. An EMR system can be used to: monitor the performance indicators of a radiotherapy department, identify workflow processes needing attention and improvement, estimate future demands of resources. Temporal analysis of our data showed an increasing trend in productivity and complexity paired with constant waiting times.

  10. Progress in the Enhanced Use of Electronic Medical Records: Data From the Ontario Experience

    Science.gov (United States)

    Koziel, Chad; Larsen, Darren; Berry, Plumaletta; Kubatka-Willms, Elena

    2017-01-01

    Background This paper describes a change management strategy, including a self-assessment survey tool and electronic medical record (EMR) maturity model (EMM), developed to support the adoption and implementation of EMRs among community-based physicians in the province of Ontario, Canada. Objective The aim of our study was to present an analysis of progress in EMR use in the province of Ontario based on data from surveys completed by over 4000 EMR users. Methods The EMM and the EMR progress report (EPR) survey tool clarify levels of capability and expected benefits of improved use. Maturity is assessed on a 6-point scale (0-5) for 25 functions, across 7 functional areas, ranging from basic to more advanced. A total of 4214 clinicians completed EPR surveys between April 2013 and March 2016. Univariate and multivariate descriptive statistics were calculated to describe the survey results. Results Physicians reported continual improvement over years of use, perceiving that the longer they used their EMR, the better patient care they provided. Those with at least two years of experience reported the greatest progress. Conclusions From our analyses at this stage we identified: (1) a direct correlation between years of EMR use and EMR maturity as measured in our model, (2) a similar positive correlation between years of EMR use and the perception that these systems improve clinical care in at least four patient-centered areas, and (3) evidence of ongoing improvement even in advanced years of use. Future analyses will be supplemented by qualitative and quantitative data collected from field staff engagements as part of the new EMR practice enhancement program (EPEP). PMID:28228372

  11. Population prevalence and control of cardiovascular risk factors: what electronic medical records tell us.

    Science.gov (United States)

    Catalán-Ramos, Arantxa; Verdú, Jose M; Grau, María; Iglesias-Rodal, Manuel; del Val García, José L; Consola, Alicia; Comin, Eva

    2014-01-01

    To analyze the prevalence, control, and management of hypertension, hypercholesterolemia, and diabetes mellitus type 2 (DM2). Cross-sectional analysis of all individuals attended in the Catalan primary care centers between 2006 and 2009. History of cardiovascular diseases, diagnosis and treatment of hypertension, hypercholesterolemia, DM2, lipid profile, glycemia and blood pressure data were extracted from electronic medical records. Age-standardized prevalence and levels of management and control were estimated. Individuals aged 35-74 years using primary care databases. A total of 2,174,515 individuals were included (mean age 52 years [SD 11], 47% men). Hypertension was the most prevalent cardiovascular risk factor (39% in women, 41% in men) followed by hypercholesterolemia (38% and 40%) and DM2 (12% and 16%), respectively. Diuretics and angiotensin-converting enzyme inhibitors were most often prescribed for hypertension control (<140/90mmHg, achieved in 68% of men and 60% of women treated). Hypercholesterolemia was controlled (low-density lipoprotein cholesterol <130mg/dl) in just 31% of men and 26% of women with no history of cardiovascular disease, despite lipid-lowering treatment, primarily (90%) with statins. The percentage of women and men with DM2 and with glycated hemoglobin <7% was 64.7% and 59.2%, respectively; treatment was predominantly with oral hypoglycemic agents alone (70%), or combined with insulin (15%). Hypertension was the most prevalent cardiovascular risk factor in the Catalan population attended at primary care centers. About two thirds of individuals with hypertension or DM2 were adequately controlled; hypercholesterolemia control was particularly low. Copyright © 2013 Elsevier España, S.L. All rights reserved.

  12. Feasibility of extracting data from electronic medical records for research: an international comparative study.

    Science.gov (United States)

    van Velthoven, Michelle Helena; Mastellos, Nikolaos; Majeed, Azeem; O'Donoghue, John; Car, Josip

    2016-07-13

    Electronic medical records (EMR) offer a major potential for secondary use of data for research which can improve the safety, quality and efficiency of healthcare. They also enable the measurement of disease burden at the population level. However, the extent to which this is feasible in different countries is not well known. This study aimed to: 1) assess information governance procedures for extracting data from EMR in 16 countries; and 2) explore the extent of EMR adoption and the quality and consistency of EMR data in 7 countries, using management of diabetes type 2 patients as an exemplar. We included 16 countries from Australia, Asia, the Middle East, and Europe to the Americas. We undertook a multi-method approach including both an online literature review and structured interviews with 59 stakeholders, including 25 physicians, 23 academics, 7 EMR providers, and 4 information commissioners. Data were analysed and synthesised thematically considering the most relevant issues. We found that procedures for information governance, levels of adoption and data quality varied across the countries studied. The required time and ease of obtaining approval also varies widely. While some countries seem ready for secondary uses of data from EMR, in other countries several barriers were found, including limited experience with using EMR data for research, lack of standard policies and procedures, bureaucracy, confidentiality, data security concerns, technical issues and costs. This is the first international comparative study to shed light on the feasibility of extracting EMR data across a number of countries. The study will inform future discussions and development of policies that aim to accelerate the adoption of EMR systems in high and middle income countries and seize the rich potential for secondary use of data arising from the use of EMR solutions.

  13. Radiological protection, safety and security issues in the industrial and medical applications of radiation sources

    Science.gov (United States)

    Vaz, Pedro

    2015-11-01

    The use of radiation sources, namely radioactive sealed or unsealed sources and particle accelerators and beams is ubiquitous in the industrial and medical applications of ionizing radiation. Besides radiological protection of the workers, members of the public and patients in routine situations, the use of radiation sources involves several aspects associated to the mitigation of radiological or nuclear accidents and associated emergency situations. On the other hand, during the last decade security issues became burning issues due to the potential malevolent uses of radioactive sources for the perpetration of terrorist acts using RDD (Radiological Dispersal Devices), RED (Radiation Exposure Devices) or IND (Improvised Nuclear Devices). A stringent set of international legally and non-legally binding instruments, regulations, conventions and treaties regulate nowadays the use of radioactive sources. In this paper, a review of the radiological protection issues associated to the use of radiation sources in the industrial and medical applications of ionizing radiation is performed. The associated radiation safety issues and the prevention and mitigation of incidents and accidents are discussed. A comprehensive discussion of the security issues associated to the global use of radiation sources for the aforementioned applications and the inherent radiation detection requirements will be presented. Scientific, technical, legal, ethical, socio-economic issues are put forward and discussed.

  14. A new method for estimating morbidity rates based on routine electronic medical records in primary care

    NARCIS (Netherlands)

    Nielen, M.; Spronk, I.; Davids, R.; Korevaar, J.; Poos, R.; Hoeymans, N.; Opstelten, W.; Sande, M. van der; Biermans, M.; Schellevis, F.; Verheij, R.

    2016-01-01

    Background & Aim: Routinely recorded electronic health records (EHRs) from general practitioners (GPs) are increasingly available and provide valuable data for estimating incidence and prevalence rates of diseases in the general population. Valid morbidity rates are essential for patient management

  15. 医保病历质量管理的实践%Practice of Quality Management of Medical Insurance Records

    Institute of Scientific and Technical Information of China (English)

    荣惠英

    2011-01-01

    通过对医疗保险病历缺陷的分析,建立病历质量控制体系,使病历质量进一步提高,以确保医保政策的执行,也促进了医疗质量和医保管理水平的提高.%Based on the analysis of deficiencies in medical records, the quality control system of medical records was set up and quality control was improved. The quality of medical records has been greatly improved which ensured the implementation of medical insurance , promoted the quality of medical and health care management level.

  16. Clinical audit teaching in record-keeping for dental undergraduates at International Medical University, Kuala Lumpur, Malaysia.

    Science.gov (United States)

    Chong, Jun A; Chew, Jamie K Y; Ravindranath, Sneha; Pau, Allan

    2014-02-01

    This study investigated the impact of clinical audit training on record-keeping behavior of dental students and students' perceptions of the clinical audit training. The training was delivered to Year 4 and Year 5 undergraduates at the School of Dentistry, International Medical University, Kuala Lumpur, Malaysia. It included a practical audit exercise on patient records. The results were presented by the undergraduates, and guidelines were framed from the recommendations proposed. Following this, an audit of Year 4 and Year 5 students' patient records before and after the audit training was carried out. A total of 100 records were audited against a predetermined set of criteria by two examiners. An email survey of the students was also conducted to explore their views of the audit training. Results showed statistically significant improvements in record-keeping following audit training. Responses to the email survey were analyzed qualitatively. Respondents reported that the audit training helped them to identify deficiencies in their record-keeping practice, increased their knowledge in record-keeping, and improved their record-keeping skills. Improvements in clinical audit teaching were also proposed.

  17. Statement on access to relevant medical and other health records and relevant legal records for forensic medical evaluations of alleged torture and other cruel, inhuman or degrading treatment or punishment

    DEFF Research Database (Denmark)

    Alempijevic, D.; Beriashvili, R.; Beynon, J.

    2013-01-01

    In some jurisdictions attempts have been made to limit or deny access to medical records for victims of torture seeking remedy or reparations or for individuals who have been accused of crimes based on confessions allegedly extracted under torture. The following article describes the importance...... professionals in acts of torture and other ill-treatment is discussed. A summary of international law and medical ethics surrounding the right of access to personal information, especially health information in connection with allegations of torture is also given....

  18. Clinical stories and medical histories recorded by Rhazes (865-925), the Iranian-Islamic physician in the medieval period.

    Science.gov (United States)

    Zohalinezhad, Mohammad E; Askari, Alireza; Farjam, Mojtaba

    2015-01-01

    Recording medical histories of patients is not a new issue in clinical medicine. However, the method practiced by the Iranian chemist physician, Rhazes, in the ninth century A.D is incredible. Rhazes has written several textbooks in clinical medicine, but a particular one, "Clinical Stories and Medical Histories" (Qesas va hekayat al-marazi), is a classical case book describing precise clinical courses of thirty three patients. Each chapter includes a title, the name and demographic data about a patient, his/her history of present illness, past medical and family history, findings of physical exam, impression and interventions by the physician, including pharmacological or surgical management. The reasons for each decision made by Rhazes as well as the outcomes are clearly discussed. This book review will shed light on the unknown medical practice methods in Islamic-Iranian golden era.

  19. Datenschutz- und Medizinprodukterecht bei Ubiquitous Computing-Anwendungen im Gesundheitssektor / Data protection and medical product law with respect to medical ubiquitous computing applications

    Directory of Open Access Journals (Sweden)

    Skistims, Hendrik

    2011-01-01

    Full Text Available With respect to ubiquitous computing there is a great potential of application, particularly in medicine and health care. This work deals with the legal problems which ubiquitous computing is facing in these areas. At the beginning, issues with respect to data protection and professional secrecy are treated. Afterwards the problem of applicability of medical product law for medical ubiquitous computing applications as well as the resulting requirements for manufactures, operators and users will be discussed.

  20. Medical record weight (MRW): a new reliable predictor of hospital stay, morbidity and mortality in the hip fracture population?

    LENUS (Irish Health Repository)

    Calpin, P

    2016-11-01

    We sought to compare the weight of patient’s medical records (MRW) to that of standardised surgical risk scoring systems in predicting postoperative hospital stay, morbidity, and mortality in patients with hip fracture. Patients admitted for surgical treatment of a newly diagnosed hip fracture over a 3-month period were enrolled. Patients with documented morbidity or mortality had significantly heavier medical records. The MRW was equivalent to the age-adjusted Charlson co-morbidity index and better than the American Society of Anaesthesiologists physical status score (ASA), the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM,) and Portsmouth-POSSUM score (P-POSSUM) in correlation with length of hospital admission, p = .003, 95% CI [.15 to .65]. Using logistic regression analysis MRW was as good as, if not better, than the other scoring systems at predicting postoperative morbidity and 90-day mortality. Medical record weight is as good as, or better than, validated surgical risk scoring methods. Larger, multicentre studies are required to validate its use as a surgical risk prediction tool, and it may in future be supplanted by a digital measure of electronic record size. Given its ease of use and low cost, it could easily be used in trauma units globally.

  1. Missing medical records: an obstacle to archival survey-research in a rural community in South Africa

    Directory of Open Access Journals (Sweden)

    L. Wegner

    2013-12-01

    Full Text Available Keeping good quality medical records is an essential yet oftenneglected part of a health-care practitioner’s workload. In South Africa, by lawall health care facilities are required to retain medical records for a minimum ofsix years after the cessation of a patient’s treatment. In an archival survey thatwas attempted in a rural community in South Africa, only 39% of the recordsthat were requested were located. The procedure that was followed in order toobtain the records to be included in the survey is briefly described in this paper,highlighting the challenges experienced in four district hospitals in this community.The phenomenon has serious implications not only for the quality of healthcare,incidence of iatrogenic injuries and the future of the health-care practitioner’s career, but it also impacts on the ability to conductresearch to inform practice. An aspect that is not often considered is the impact of poor record keeping on the research and teachingcomponent of the broader medical profession.

  2. Retrieval and management of medical information from heterogeneous sources, for its integration in a medical record visualisation tool.

    Science.gov (United States)

    Cabarcos, Alba; Sanchez, Tamara; Seoane, Jose A; Aguiar-Pulido, Vanessa; Freire, Ana; Dorado, Julian; Pazos, Alejandro

    2010-01-01

    Nowadays, medical practice needs, at the patient Point-of-Care (POC), personalised knowledge adjustable in each moment to the clinical needs of each patient, in order to provide support to decision-making processes, taking into account personalised information. To achieve this, adapting the hospital information systems is necessary. Thus, there is a need of computational developments capable of retrieving and integrating the large amount of biomedical information available today, managing the complexity and diversity of these systems. Hence, this paper describes a prototype which retrieves biomedical information from different sources, manages it to improve the results obtained and to reduce response time and, finally, integrates it so that it is useful for the clinician, providing all the information available about the patient at the POC. Moreover, it also uses tools which allow medical staff to communicate and share knowledge.

  3. 病历质控须从细处入手%Quality Control of Medical Records should start with Details

    Institute of Scientific and Technical Information of China (English)

    蔡青; 衡爱萍; 雷光文; 周玉萍

    2012-01-01

    Objectives to achieve effect control of medical records quality and to improve connotation quality of m edical records. M eihods This paper puts forwards methods for quality control as follow ings: perfection of rules and regulations and standardization of m edical records m anagem ent; starting w i1h w riting details of m edical records, it finds out quality problem s and solves tim ely; com m unicatfon w i1h doctors tim ely for reducing cognitive deviation; value on connotation quality of medical records, key segm ents control, effect con trolof running medical records, careful evaluation about final medical records and in plem ent of rew ard for excellent and punishm ent for bad. R esulte T hrough quality control of m edical records, 1he m edical records w riting of hospital becomemore rigorous and m ediclbehavior becom emore standard; the rate of defects incidence of m edicalrecords quality decreases gradually; connotation quality of medical records in proves obviously; 1he rate of ckss-A is up to 96 .8% ; 1he rate of tim ely filing is up to 100% . C onclusbns T he quality control of medical records cannot be done by one go. T he m anager of m edical records quality should fully realize that 1he bng-time, rigorous, allrelated person and innovation of quality control becom e effective only in a persistent w ay through by day by.%目的 实现病历质量有效控制,提高病历内涵质量.方法 健全规章制度,规范病历管理;从病历书写细处着眼,从点滴抓起,查找质量问题并及时解决;及时与医生沟通,减少认识偏差;注重病历内涵质量,掌控关键环节,有效监控运行病历,认真评审终末病历,实行奖优惩劣.结果 通过病历质量控制,医院的病历书写更加严谨,医疗行为更加规范,病历质量缺陷发生率逐年下降,病历内涵质量明显提高,甲级率逐年上升达到96.8%,及时归档率达100%.结论 病历质量控制并非一蹴而就,病历质量管理者要充分认识到病

  4. 42 CFR 480.131 - Access to medical records for the monitoring of QIOs.

    Science.gov (United States)

    2010-10-01

    ... HEALTH AND HUMAN SERVICES (CONTINUED) QUALITY IMPROVEMENT ORGANIZATIONS ACQUISITION, PROTECTION, AND... for the monitoring of QIOs. CMS or any person, organization or agency authorized by the Department...

  5. Physician assessment of disease activity in JIA subtypes. Analysis of data extracted from electronic medical records

    Directory of Open Access Journals (Sweden)

    Wang Deli

    2011-04-01

    Full Text Available Abstract Objective Although electronic medical records (EMRs have facilitated care for children with juvenile idiopathic arthritis (JIA, analyses of treatment outcomes have required paper based or manually re-entered data. We have started EMR discrete data entry for JIA patient visits, including joint examination and global assessment, by physician and patient. In this preliminary study, we extracted data from the EMR to Xenobase™ (TransMed Systems, Inc., Cupertino, CA, an application permitting cohort analyses of the relationship between global assessment to joint examination and subtype. Methods During clinic visits, data were entered into discrete fields in ambulatory visit forms in the EMR (EpicCare™, Epic Systems, Verona, WI. Data were extracted using Clarity Reports, then de-identified and uploaded for analyses to Xenobase™. Parameters included joint examination, ILAR diagnostic classification, physician global assessment, patient global assessment, and patient pain score. Data for a single visit for each of 160 patients over a 2 month period, beginning March, 2010, were analyzed. Results In systemic JIA patients, strong correlations for physician global assessment were found with pain score, joint count and patient assessment. In contrast, physician assessment for patients with persistent oligoarticular and rheumatoid factor negative patients showed strong correlation with joint counts, but only moderate correlation with pain scores and patient global assessment. Conversely, for enthesitis patients, physician assessment correlated strongly with pain scores, and moderately with joint count and patient global assessment. Rheumatoid factor positive patients, the smallest group studied, showed moderate correlation for all three measures. Patient global assessment for systemic patients showed strong correlations with pain scores and joint count, similar to data for physician assessment. For polyarticular and enthesitis patients

  6. 某省县级结核病防治门诊病案质量调查与分析%Investigation of Medical Record Quality in County Level Tuberculosis Control Clinics in One Province

    Institute of Scientific and Technical Information of China (English)

    陈丹声; 陈求扬; 林淑芳; 林勇明

    2011-01-01

    Objective To investigate medical record quality in county level tuberculosis (TB) clinics in Fujian, to provide reference for the formulation of policy. Method Through a random check of medical record information in county level TB clinic for one year registration of active TB patients, the unified design of table was investigated. Result During the five years, the majority of medical record for patients with active TB had been tidied up timely on request. Among the medical record, some documents were well collected, including report of liver function tests, X - ray examination report, treatment agreement, treatment and management feedback, medication treatment supervision card. However, the collection of sputum smear examination report had to be improved; and most of the medical records were relatively simple. Conclusion The quality of county level medical records for active TB patients gradually improved in Fujian province. The quality awareness should be improved and medical record data collection and writing should be strengthened among out - patient doctors ; and the medical self - protection awareness must be strengthened to standardize written medical record.%目的 了解福建省县级结核病防治门诊病案质量现状,为制定政策提供参考依据.方法 随机抽查县级结核病防治门诊登记满1年的活动性肺结核患者病案资料,根据统一设计的表格进行检查.结果 5年间,大多数活动性肺结核痛患者的病案资料已按要求及时整理归档;抽查的病案资料中,肝功能检查报告单、X线检查报告单、治疗协议书、治疗管理反馈单与服药督导卡等单据收集较完整,但痰涂片检查报告单的收集还有待改进;大多数病案记录相对简单.结论 福建省县级活动性肺结核痛患者病案资料质量逐步提高;应提高结核病防治门诊医生质量意识,加强病案资料的收集;必须强化结核病防治门诊医生自我保护的意识,规范书写病案.

  7. Patient-Oriented Improvement Measures of Medical Record Copying in a Grade A Tertiary Hospital%某三甲医院“以患者为中心”改进病案复印措施探讨

    Institute of Scientific and Technical Information of China (English)

    赵学英; 李禾

    2015-01-01

    随着医疗制度的改革与完善,以及人们自我保护意识和法律意识的逐步提高,患者需求复印住院病案日益增多。病案资料复印已成为病案管理服务工作中的重要组成部分。总结归纳近5年某三级甲等医院病案科复印室工作的效果与经验,提出以患者为中心的病案科复印工作模式。通过做好宣传、开展预约复印邮寄业务、床旁预约复印、督促病历回收等多种方式的改进措施,来满足快速增长的病案复印需求,规范病案复印服务,减少医患纠纷,创造构建和谐的医患关系。病案科管理者必须转变观念,以患者为中心,既符合复印相关的法律法规规定,又要为患者提供满意、优质、高效的服务。%As the reform and perfect of medical system, and the gradual improvement of the ego to protect consciousness and the legal consciousness, patients’demand of medical record is increasing. Medical record copy has become an important part of medical record management and service work. Summarize effect and the experience of medical record copy work in a grade a tertiary hospital in recent five years, and Put forward the patient centered medical record copy work idea mode. We should do publicity, carry out the booking copy mail business, bedside booking copy, and urge medical records recycling and other measures, to meet the needs of rapid growth in the actual work, and Standardize medical record copy services, reduce medical disputes, create a harmonious doctor-patient relationship. Medical record department managers must change concept, taking patients as the center, not only comply with relevant laws and regulations, but also provide patients with quality and efficient services.

  8. Measuring Maturity of Use for Electronic Medical Records (EMRs) in British Columbia: The Physician Information Technology Office (PITO).

    Science.gov (United States)

    Rimmer, Carol; Hagens, Simon; Baldwin, Anne; Anderson, Carol J

    2014-01-01

    This article examines British Columbia (BC)'s Physician Information Technology Office's efforts to measure and improve the use of electronic medical records (EMRs) by select practices in BC with an assessment of their progress using a maturity model, and targeted support. The follow-up assessments showed substantial increases in the physicians' scores resulting from action plans that comprised a series of tailored support activities. Specifically, there was an increase from 21% to 83% of physicians who could demonstrate that they used their EMRs as the principal method of record-keeping.

  9. 75 FR 1446 - Rate of Payment for Medical Records Received Through Health Information Technology (IT) Necessary...

    Science.gov (United States)

    2010-01-11

    ... experiencing a significant increase in the number of initial claims for disability insurance benefits and... disability insurance benefits and SSI payments on the basis of disability must provide medical evidence to... benefits. We rely on medical providers such as doctors, hospitals, clinics, and others in the healthcare...

  10. MOLLUSC SPECIES PROTECTED IN POLAND AND THREATENED IN EUROPE RECORDED IN STEPNICA RIVER (NW POLAND

    Directory of Open Access Journals (Sweden)

    Małgorzata Raczyńska

    2014-10-01

    Full Text Available In the course of the study two bivalve species protected in Poland were found in the river Stepnica: Sphaerium solidum and Sphaerium rivicola. Moreover, the study material collected from the river contained gastropod and bivalve specimens representing the following species from the IUCN Red List of Threatened Species: Theodoxus fluviatilis, Pisidium henslowanum, Pisidium casertanum and Pisidium pseudosphaerium.

  11. Radiation Protection of Medical Personnel%医护人员的放射防护

    Institute of Scientific and Technical Information of China (English)

    张冠石

    2013-01-01

    医院放射防护项目是为了降低患者和医护人员受到的放射性辐射,保护他们的健康和权益.医院放射防护项目的指导思想是放射防护最优化(As Low as Reasonably Achievable,ALARA)方案,其主旨是根据具体操作和照射部位来调整并优化放射诊疗方案.%The purpose of radiation safety programs in hospitals is to lower the radiation dose received by patients and medical personnel,and to protect their health.The guideline for radiation safety programs is ALARA (As Low As Reasonably Achievable) law,which is intended to adjust diagnostic and therapeutic techniques according to specific radiation operation and the photographed part of the body.

  12. A simulated hospital pharmacy module using an electronic medical record in a pharmaceutical care skills laboratory course.

    Science.gov (United States)

    Kirwin, Jennifer L; DiVall, Margarita V; Guerra, Christina; Brown, Todd

    2013-04-12

    OBJECTIVES. To implement and evaluate the effects of a simulated hospital pharmacy module using an electronic medical record on student confidence and abilities to perform hospital pharmacist duties. DESIGN. A module was developed that simulated typical hospital pharmacist tasks. Learning activities were modified based upon student feedback and instructor assessment. ASSESSMENTS. Ninety-seven percent of respondents reported full-time hospital internship experience and 72% had electronic medical record experience prior to completing the module. Mean scores on confidence with performing typical hospital pharmacist tasks significantly increased from the pre-module survey to the post-module survey from 1.5-2.9 (low comfort/confidence) to 2.0-3.4 (moderate comfort/confidence). Course assessments confirmed student achievement of covered competencies. CONCLUSIONS. A simulated hospital pharmacy module improved pharmacy students' hospital practice skills and their perceived comfort and confidence in completing the typical duties of a hospital pharmacist.

  13. Measures of Strengthening the Medical Records Management%加强病案管理的举措

    Institute of Scientific and Technical Information of China (English)

    王弥; 安妍; 苟淑梅

    2011-01-01

    To discuss the effective measures of improving medical records management and it' s performance. Monitor the distribution of medicalrecord number by compurer program to ensure the correct medical record number. At the same time the warehouse management process has been optimized. There is an importrant significance of improproving management skills.%以实例论述了医院为改进病案管理、提高病案管理绩效的有效措施.通过计算机程序限定病案号派发实施监控,从而保证病案编号方式的正确;同时对病案库房流程进行了优化设计,提高了工作效率.管理人员职能协作,提高管理技能在病案管理中具有重要意义.

  14. Records Management

    Data.gov (United States)

    U.S. Environmental Protection Agency — All Federal Agencies are required to prescribe an appropriate records maintenance program so that complete records are filed or otherwise preserved, records can be...

  15. Optimization of the workers radiation protection in the electro nuclear, industrial and medical fields; Optimisation de la radioprotection des travailleurs dans les domaines electronucleaire, industriel et medical

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    1998-07-01

    This conference is devoted to the radiation protection and the best way to optimize it. It reviews each area of the nuclear industry, and explores also the medical sector. Dosimetry, ALARA principle and new regulation are important points of this meeting. (N.C.)

  16. OCCURRENCE OF FAULT RECORDS OF NURSING CARE IN A HOSPITAL MEDICAL UNIT

    Directory of Open Access Journals (Sweden)

    Paula Bresolin

    2013-09-01

    Full Text Available The nursing records have value as a procedural document, source of inquiry and teaching tool. It is worth mentioning that, the records are actions performed through care processes, generating revenue for the institutions.The objective of this study was to identify the major record failures of nursing care. The survey was conducted in an Adult Clinic of a private hospital in Caxias do Sul, in the period of March to April, 2012. Data were collected through the reporting of the auditorship service and through the application of a questionnaire to the nursing staff. The main problems found were the lack of scheduling, checks and nursing records, the incorrect materials and drugs request by nursing, mistakes in prescriptions and imcomplete forms. From the problems identified it is suggested the intensification of continuing education on nursing records and further studies to identify the economic value lost by glosses in hospital bills.

  17. A medical record of lumbar disc herniation%腰间盘突出医案一则

    Institute of Scientific and Technical Information of China (English)

    陈艳艳; 杨秋茹; 侯献兵

    2016-01-01

    本文介绍腰间盘突出医案一则,可知针灸治疗腰间盘突出确有实效,为相关治疗提供参考。%In this article, a medical record of treating lumbar disc herniation was introduced;a deifnite effcacy of acupuncture on lumbar disc herniation was showed;and this study provided more reference for relevant treatment.

  18. Using electronic medical records to determine prevalence and treatment of mental disorders in primary care: a database study

    OpenAIRE

    Gleeson, M; Hannigan, Ailish; Jamali, R; Su Lin, K; Klimas, Jan; Mannix, M; Nathan, Yoga; O'Connor, R; O'Gorman, Clodagh S.; Dunne, Colum; Meagher, David; Cullen, Walter

    2015-01-01

    peer-reviewed Objectives: With prevention and treatment of mental disorders a challenge for primary care and increasing capability of electronic medical records (EMRs) to facilitate research in practice, we aim to determine the prevalence and treatment of mental disorders by using routinely collected clinical data contained in EMRs. Methods: We reviewed EMRs of patients randomly sampled from seven general practices, by piloting a study instrument and extracting data on menta...

  19. Physician user satisfaction with an electronic medical records system in primary healthcare centres in Al Ain: a qualitative study

    OpenAIRE

    Al Alawi, Shamma; Al Dhaheri, Aysha; Al Baloushi, Durra; Al Dhaheri, Mouza; Engela A. M. Prinsloo

    2014-01-01

    Objectives To explore physician satisfaction with an electronic medical records (EMR) system, to identify and explore the main limitations of the system and finally to submit recommendations to address these limitations. Design A descriptive qualitative study that entailed three focus group interviews was performed among physicians using open-ended questions. The interviews were audiotaped, documented and transcribed verbatim. The themes were explored and analysed in different categories. Set...

  20. Guidelines on the implementation of radiation protection measures during diagnostic medical exposures of female patients of reproductive capacity

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2000-08-01

    These guidelines were produced in response to a perceived need for clear guidance concerning the implementation of the 10-day and 28-day rules regarding radiological radiation protection practices. At the outset it is important to emphasise that, in all cases, the seriousness of the clinical situation must be taken into account as being of paramount importance and an overriding consideration to the guidelines. Radiographs of the chest, skull and extremities may be done at any time, provided that best practices are adhered to. All requests for radiological examinations of female patients, which place the uterus in or near the primary X-ray beam, i.e. irradiation between the diaphragm and pubis, or nuclear medicine examinations which are likely to result in a dose to the unborn child up to 10 mGy, should include the date of the last menstrual period. The prescriber and practitioner or radiographer should ask a patient beyond day 10 of the menstrual cycle whether she might be pregnant. This enquiry and the patient's answer should be recorded in writing. If the answer is no, the examination may proceed. If the answer is yes or uncertain, the examination should not proceed. In cases of medical emergency, the practitioner or the prescriber, if necessary following discussion with the practitioner or radiographer and taking justification into account, may decide to proceed with the examination. The practitioner or prescriber must record this decision in writing and sign it. The 10-day rule is recommended for certain high dose examinations where the dose to the uterus is likely to exceed 10 mGy. These include a small number of diagnostic X-ray and nuclear medicine procedures. (author)