WorldWideScience

Sample records for patient medical records

  1. Medical ADP Systems: Automated Medical Records Hold Promise to Improve Patient Care

    Science.gov (United States)

    1991-01-01

    automated medical records. The report discusses the potential benefits that automation could make to the quality of patient care and the factors that impede...information systems, but no organization has fully automated one of the most critical types of information, patient medical records. The patient medical record...its review of automated medical records. GAO’s objectives in this study were to identify the (1) benefits of automating patient records and (2) factors

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

    Science.gov (United States)

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

    2011-02-01

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

  3. How patients can improve the accuracy of their medical records.

    Science.gov (United States)

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

    2014-01-01

    Assess (1) if patients can improve their medical records' accuracy if effectively engaged using a networked Personal Health Record; (2) workflow efficiency and reliability for receiving and processing patient feedback; and (3) patient feedback's impact on medical record accuracy. Improving medical record' accuracy and associated challenges have been documented extensively. Providing patients with useful access to their records through information technology gives them new opportunities to improve their records' accuracy and completeness. A new approach supporting online contributions to their medication lists by patients of Geisinger Health Systems, an online patient-engagement advocate, revealed this can be done successfully. In late 2011, Geisinger launched an online process for patients to provide electronic feedback on their medication lists' accuracy before a doctor visit. Patient feedback was routed to a Geisinger pharmacist, who reviewed it and followed up with the patient before changing the medication list shared by the patient and the clinicians. The evaluation employed mixed methods and consisted of patient focus groups (users, nonusers, and partial users of the feedback form), semi structured interviews with providers and pharmacists, user observations with patients, and quantitative analysis of patient feedback data and pharmacists' medication reconciliation logs. (1) Patients were eager to provide feedback on their medications and saw numerous advantages. Thirty percent of patient feedback forms (457 of 1,500) were completed and submitted to Geisinger. Patients requested changes to the shared medication lists in 89 percent of cases (369 of 414 forms). These included frequency-or dosage changes to existing prescriptions and requests for new medications (prescriptions and over-the counter). (2) Patients provided useful and accurate online feedback. In a subsample of 107 forms, pharmacists responded positively to 68 percent of patient requests for

  4. Patients prefer electronic medical records - fact or fiction?

    Science.gov (United States)

    Masiza, Melissa; Mostert-Phipps, Nicky; Pottasa, Dalenca

    2013-01-01

    Incomplete patient medical history compromises the quality of care provided to a patient while well-kept, adequate patient medical records are central to the provision of good quality of care. According to research, patients have the right to contribute to decision-making affecting their health. Hence, the researchers investigated their views regarding a paper-based system and an electronic medical record (EMR). An explorative approach was used in conducting a survey within selected general practices in the Nelson Mandela Metropole. The majority of participants thought that the use of a paper-based system had no negative impact on their health. Participants expressed concerns relating to the confidentiality of their medical records with both storage mediums. The majority of participants indicated they prefer their GP to computerise their consultation details. The main objective of the research on which this poster is based was to investigate the storage medium of preference for patients and the reasons for their preference. Overall, 48% of the 85 participants selected EMRs as their preferred storage medium and the reasons for their preference were also uncovered.

  5. Patient-centred care: using online personal medical records in IVF practice.

    NARCIS (Netherlands)

    Tuil, W.S.; Hoopen, A.J. ten; Braat, D.D.M.; Vries Robbé, P.F. de; Kremer, J.A.M.

    2006-01-01

    BACKGROUND: Generic patient-accessible medical records have shown promise in enhancing patient-centred care for patients with chronic diseases. We sought to design, implement and evaluate a patient-accessible medical record specifically for patients undergoing a course of assisted reproduction (IVF

  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

    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......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. 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.

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

    Science.gov (United States)

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

    2015-07-12

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

  9. Patients want granular privacy control over health information in electronic medical records.

    Science.gov (United States)

    Caine, Kelly; Hanania, Rima

    2013-01-01

    To assess patients' desire for granular level privacy control over which personal health information should be shared, with whom, and for what purpose; and whether these preferences vary based on sensitivity of health information. A card task for matching health information with providers, questionnaire, and interview with 30 patients whose health information is stored in an electronic medical record system. Most patients' records contained sensitive health information. No patients reported that they would prefer to share all information stored in an electronic medical record (EMR) with all potential recipients. Sharing preferences varied by type of information (EMR data element) and recipient (eg, primary care provider), and overall sharing preferences varied by participant. Patients with and without sensitive records preferred less sharing of sensitive versus less-sensitive information. Patients expressed sharing preferences consistent with a desire for granular privacy control over which health information should be shared with whom and expressed differences in sharing preferences for sensitive versus less-sensitive EMR data. The pattern of results may be used by designers to generate privacy-preserving EMR systems including interfaces for patients to express privacy and sharing preferences. To maintain the level of privacy afforded by medical records and to achieve alignment with patients' preferences, patients should have granular privacy control over information contained in their EMR.

  10. Medical records and issues in negligence

    Directory of Open Access Journals (Sweden)

    Joseph Thomas

    2009-01-01

    Full Text Available 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 establishments to properly maintain the records of patients for two important reasons. The first one is that it will help them in the scientific evaluation of their patient profile, helping in analyzing the treatment results, and to plan treatment protocols. It also helps in planning governmental strategies for future medical care. But of equal importance in the present setting is in the issue of alleged medical negligence. The legal system relies mainly on documentary evidence in a situation where medical negligence is alleged by the patient or the relatives. In an accusation of negligence, this is very often the most important evidence deciding on the sentencing or acquittal of the doctor. With the increasing use of medical insurance for treatment, the insurance companies also require proper record keeping to prove the patient′s demand for medical expenses. Improper record keeping can result in declining medical claims. It is disheartening to note that inspite of knowing the importance of proper record keeping it is still in a nascent stage in India. It is wise to remember that "Poor records mean poor defense, no records mean no defense". Medical records include a variety of documentation of patient′s history, clinical findings, diagnostic test results, preoperative care, operation notes, post operative care, and daily notes of a patient′s progress and medications. A properly obtained consent will go a long way in proving that the procedures were

  11. Your Medical Records

    Science.gov (United States)

    ... hear medical people call these EHRs — short for electronic health records . Electronic records make it easier for all your doctors ... doctor's office is trying to protect a patient's privacy or safety. For example, they may say no ...

  12. Image-based electronic patient records for secured collaborative medical applications.

    Science.gov (United States)

    Zhang, Jianguo; Sun, Jianyong; Yang, Yuanyuan; Liang, Chenwen; Yao, Yihong; Cai, Weihua; Jin, Jin; Zhang, Guozhen; Sun, Kun

    2005-01-01

    We developed a Web-based system to interactively display image-based electronic patient records (EPR) for secured intranet and Internet collaborative medical applications. The system consists of four major components: EPR DICOM gateway (EPR-GW), Image-based EPR repository server (EPR-Server), Web Server and EPR DICOM viewer (EPR-Viewer). In the EPR-GW and EPR-Viewer, the security modules of Digital Signature and Authentication are integrated to perform the security processing on the EPR data with integrity and authenticity. The privacy of EPR in data communication and exchanging is provided by SSL/TLS-based secure communication. This presentation gave a new approach to create and manage image-based EPR from actual patient records, and also presented a way to use Web technology and DICOM standard to build an open architecture for collaborative medical applications.

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

    Science.gov (United States)

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

    2018-06-01

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

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

    Science.gov (United States)

    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 survey undertaken by the working group developing the performance procedures for microbiology, to identify current practice and to develop recommendations for agreement within the profession about the standards of the microbiological record. The cumulative frequency for the surveyed recording methods used indicated that at various times 65% (90 of 139) of respondents used a daybook, 62% (86 of 139) used the back of the clinical request card, 57% (79 of 139) used a computer record, and 22% (30 of 139) used an index card system to record microbiological advice, suggesting wide variability in relation to how medical microbiologists maintain clinical records. PMID:12499432

  15. [Computerized medical record: deontology and legislation].

    Science.gov (United States)

    Allaert, F A; Dusserre, L

    1996-02-01

    Computerization of medical records is making headway for patients' follow-up, scientific research, and health expenses control, but it must not alter the guarantees provided to the patients by the medical code of ethics and the law of January 6, 1978. This law, modified on July 1, 1994, requires to register all computerized records of personal data and establishes rights to protect privacy against computer misdemeanor. All medical practitioners using computerized medical records must be aware that the infringement of this law may provoke suing in professional, civil or criminal court.

  16. The PHARMS (Patient Held Active Record of Medication Status) feasibility study: a research proposal.

    LENUS (Irish Health Repository)

    Walsh, Elaine

    2018-01-08

    Medication errors are a major source of preventable morbidity, mortality and cost and many occur at the times of hospital admission and discharge. Novel interventions (such as new methods of recording medication information and conducting medication reconciliation) are required to facilitate accurate transfer of medication information. With existing evidence supporting the use of information technology and the patient representing the one constant in the care process, an electronic patient held medication record may provide a solution. This study will assess the feasibility of introducing a patient held electronic medication record in primary and secondary care using the Consolidated Framework for Implementation Research (CFIR).This feasibility study is a mixed method study of community dwelling older adult patients admitted to an urban secondary care facility comprising a non-randomised intervention and qualitative interviews with key stakeholders. Outcomes of interest include clinical outcomes and process evaluation.This study will yield insights pertaining to feasibility, acceptability and participation for a more definitive evaluation of the intervention. The study also has the potential to contribute to knowledge of implementation of technology in a healthcare context and to the broader area of implementation science.

  17. Using the Electronic Medical Record to Enhance Physician-Nurse Communication Regarding Patients' Discharge Status.

    Science.gov (United States)

    Driscoll, Molly; Gurka, David

    2015-01-01

    The fast-paced environment of hospitals contributes to communication failures between health care providers while impacting patient care and patient flow. An effective mechanism for sharing patients' discharge information with health care team members is required to improve patient throughput. The communication of a patient's discharge plan was identified as crucial in alleviating patient flow delays at a tertiary care, academic medical center. By identifying the patients who were expected to be discharged the following day, the health care team could initiate discharge preparations in advance to improve patient care and patient flow. The patients' electronic medical record served to convey dynamic information regarding the patients' discharge status to the health care team via conditional discharge orders. Two neurosciences units piloted a conditional discharge order initiative. Conditional discharge orders were designed in the electronic medical record so that the conditions for discharge were listed in a dropdown menu. The health care team was trained on the conditional discharge order protocol, including when to write them, how to find them in the patients' electronic medical record, and what actions should be prompted by these orders. On average, 24% of the patients discharged had conditional discharge orders written the day before discharge. The average discharge time for patients with conditional discharge orders decreased by 83 minutes (0.06 day) from baseline. Qualitatively, the health care team reported improved workflows with conditional orders. The conditional discharge orders allowed physicians to communicate pending discharges electronically to the multidisciplinary team. The initiative positively impacted patient discharge times and workflows.

  18. 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…

  19. 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

  20. 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

    2018-02-01

    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

  1. Antidepressant medication use for primary care patients with and without medical comorbidities: a national electronic health record (EHR) network study.

    Science.gov (United States)

    Gill, James M; Klinkman, Michael S; Chen, Ying Xia

    2010-01-01

    Because comorbid depression can complicate medical conditions (eg, diabetes), physicians may treat depression more aggressively in patients who have these conditions. This study examined whether primary care physicians prescribe antidepressant medications more often and in higher doses for persons with medical comorbidities. This secondary data analysis of electronic health record data was conducted in the Centricity Health Care User Research Network (CHURN), a national network of ambulatory practices that use a common outpatient electronic health record. Participants included 209 family medicine and general internal medicine providers in 40 primary care CHURN offices in 17 US states. Patients included adults with a new episode of depression that had been diagnosed during the period October 2006 through July 2007 (n = 1513). Prescription of antidepressant medication and doses of antidepressant medication were compared for patients with and without 6 comorbid conditions: diabetes, coronary heart disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, and cancer. 20.7% of patients had at least one medical comorbidity whereas 5.8% had multiple comorbidities. Overall, 77% of depressed patients were prescribed antidepressant medication. After controlling for age and sex, patients with multiple comorbidities were less likely to be prescribed medication (adjusted odds ratio, 0.58; 95% CI, 0.35-0.96), but there was no significant difference by individual comorbidities. Patients with cerebrovascular disease were less likely to be prescribed a full dose of medication (adjusted odds ratio, 0.26; 95% CI, 0.08-0.88), but there were no differences for other comorbidities or for multiple comorbidities, and there was no difference for any comorbidities in the prescription of minimally effective doses. Patients with new episodes of depression who present to a primary care practice are not treated more aggressively if they have medical

  2. Overcoming Structural Constraints to Patient Utilization of Electronic Medical Records: A Critical Review and Proposal for an Evaluation Framework

    OpenAIRE

    Winkelman, Warren J.; Leonard, Kevin J.

    2004-01-01

    There are constraints embedded in medical record structure that limit use by patients in self-directed disease management. Through systematic review of the literature from a critical perspective, four characteristics that either enhance or mitigate the influence of medical record structure on patient utilization of an electronic patient record (EPR) system have been identified: environmental pressures, physician centeredness, collaborative organizational culture, and patient centeredness. An ...

  3. [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.

  4. [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.

  5. Visual patient records

    NARCIS (Netherlands)

    Luu, M.D.

    2015-01-01

    Patient information is often complex and fragmented; visualization can help to obtain and communicate insights. To move from paper medical records to interactive and visual patient records is a big challenge. This project aims to move towards this ultimate goal by providing an interactive prototype

  6. Pervasive Electronic Medical Record

    African Journals Online (AJOL)

    Nafiisah

    independent web service connected to database of medical records or Worldwide. Interoperability ... allows wireless monitoring and tracking of patients and first responders using sensor nodes .... All these network security threats arise mainly ...

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

    Science.gov (United States)

    Levy, Michael

    2016-01-01

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

  8. Patients' thoughts on patient- retained medical records

    African Journals Online (AJOL)

    was also thought to motivate the patients to act on the advice given, and the records also served as a reminder to take their ... to use it and to standardise the information that is recorded; and health planners should be motivated to implement .... Table I: Combined list of themes identified and quotations supporting them.

  9. 42 CFR 416.47 - Condition for coverage-Medical records.

    Science.gov (United States)

    2010-10-01

    ... accurate medical records to ensure adequate patient care. (a) Standard: Organization. The ASC must develop and maintain a system for the proper collection, storage, and use of patient records. (b) Standard...) Patient identification. (2) Significant medical history and results of physical examination. (3) Pre...

  10. Evaluation of medical records maintenance quality in dental medical organizations of Kazan

    Directory of Open Access Journals (Sweden)

    A K Lapina

    2018-02-01

    Full Text Available Aim. Improvement of the quality control of dental medical organizations when diagnosing dentoalveolar anomalies and deformities. Methods. A retrospective analysis of an orthodontic patient’s medical record maintenance at the dental clinics of Kazan. Results. Only 30.7% of all the verified documentation were established to be most thoroughly and correctly filled. Information about the obligatory medical insurance policy was indicated only in 2 cards out of all the verified documentation. In all orthodontic patient medical records the fringe benefit category code was absent. The name of the insurance organization in which a patient was unsured, was available only in 2.3% of the cards. Patient’s passport data were available only in 14 (15.9% cards, and the type of payment for services was registered only in 38 (43.2%. The diagnosis established by a referring medical organization was indicated only in 7 (8% of the records. When examining the dental rows of patients, their dimensions and apical bases of the jaws, the shape of the dentition were indicated in 40.9% of the documentation. The contact of adjacent teeth was described in 36.4% of all cases, presence of diastema between the upper jaw incisors was represented in 30.7% of the medical charts of orthodontic patients. The diastema between the lower jaw incisors was reflected in 25 (28.4% medical charts of orthodontic patients. Based on the doctor’s notes in the medical records, it is difficult to understand whether the whole necessary list of diagnostic measures had been performed to the patient in order to confirm this or that orthodontic pathology. Such filling of the medical chart of orthodontic patient at times makes the experts doubt in the correctness of diagnosis of a certain patient. Conclusion. Doctors-orthodontists do not pay enough attention to the collection of anamnesis of the disease, evaluation of the nature of complaints, as well as use of basic and additional methods of

  11. Ethics of medical records and professional communications.

    Science.gov (United States)

    Recupero, Patricia R

    2008-01-01

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

  12. Incidence and cost of medications dispensed despite electronic medical record discontinuation.

    Science.gov (United States)

    Baranowski, Patrick J; Peterson, Kristin L; Statz-Paynter, Jamie L; Zorek, Joseph A

    2015-01-01

    To determine the incidence and cost of medications dispensed despite discontinuation (MDDD) of the medications in the electronic medical record within an integrated health care organization. Dean Health System, with medical clinics and pharmacies linked by an electronic medical record, and a shared health plan and pharmacy benefits management company. Pharmacist-led quality improvement project using retrospective chart review. Electronic medical records, pharmacy records, and prescription claims data from patients 18 years of age or older who had a prescription filled for a chronic condition from June 2012 to August 2013 and submitted a claim through the Dean Health Plan were aggregated and cross-referenced to identify MDDD. Descriptive statistics were used to characterize demographics and MDDD incidence. Fisher's exact test and independent samples t tests were used to compare MDDD and non-MDDD groups. Wholesale acquisition cost was applied to each MDDD event. 7,406 patients met inclusion criteria. For 223 (3%) patients with MDDD, 253 independent events were identified. In terms of frequency per category, antihypertensive agents topped the list, followed, in descending order, by anticonvulsants, antilipemics, antidiabetics, and anticoagulants. Nine medications accounted for 59% (150 of 253) of all MDDD events; these included (again in descending order): gabapentin, atorvastatin, simvastatin, hydrochlorothiazide, lisinopril, warfarin, furosemide, metformin, and metoprolol. Mail-service pharmacies accounted for the highest incidence (5.3%) of MDDD, followed by mass merchandisers (4.6%) and small chains (3.9%). The total cost attributable to MDDD was $9,397.74. Development of a technology-based intervention to decrease the incidence of MDDD may be warranted to improve patient safety and decrease health care costs.

  13. 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.

  14. 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.

  15. Visualization index for image-enabled medical records

    Science.gov (United States)

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

    2011-03-01

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

  16. 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.

  17. 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.

  18. Electronic medical records for otolaryngology office-based practice.

    Science.gov (United States)

    Chernobilsky, Boris; Boruk, Marina

    2008-02-01

    Pressure is mounting on physicians to adopt electronic medical records. The field of health information technology is evolving rapidly with innovations and policies often outpacing science. We sought to review research and discussions about electronic medical records from the past year to keep abreast of these changes. Original scientific research, especially from otolaryngologists, is lacking in this field. Adoption rates are slowly increasing, but more of the burden is shouldered by physicians despite policy efforts and the clear benefits to third-party payers. Scientific research from the past year suggests lack of improvements and even decreasing quality of healthcare with electronic medical record adoption in the ambulatory care setting. The increasing prevalence and standardization of electronic medical record systems results in a new set of problems including rising costs, audits, difficulties in transition and public concerns about security of information. As major players in healthcare continue to push for adoption, increased effort must be made to demonstrate actual improvements in patient care in the ambulatory care setting. More scientific studies are needed to demonstrate what features of electronic medical records actually improve patient care. Otolaryngologists should help each other by disseminating research about improvement in patient outcomes with their systems since current adoption and outcomes policies do not apply to specialists.

  19. 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...

  20. AVAILABILITY, ACCESSIBILITY, PRIVACY AND SAFETY ISSUES FACING ELECTRONIC MEDICAL RECORDS

    OpenAIRE

    Nisreen Innab

    2018-01-01

    Patient information recorded in electronic medical records is the most significant set of information of the healthcare system. It assists healthcare providers to introduce high quality care for patients. The aim of this study identifies the security threats associated with electronic medical records and gives recommendations to keep them more secured. The study applied the qualitative research method through a case study. The study conducted seven interviews with medical staff and informatio...

  1. 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...

  2. 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

  3. The use of electronic patient records for medical research: conflicts and contradictions.

    Science.gov (United States)

    Stevenson, Fiona

    2015-03-29

    The use of electronic patient records for medical research is extremely topical. The Clinical Practice Research Datalink (CRPD), the English NHS observational data and interventional research service, was launched in April 2012. The CPRD has access to, and facilities to link, many healthcare related datasets. The CPRD is partially based on learning from the Health Research Support Service (HRSS), which was used to test the technical and practical aspects of downloading and linking electronic patient records for research. Questions around the feasibility and acceptability of implementing and integrating the processes necessary to enable electronic patient records to be used for the purposes of research remain. Focus groups and interviews were conducted with a total of 50 patients and 7 staff from the two English GP practices involved in piloting the HRSS, supplemented with 11 interviews with key stakeholders. Emergent themes were mapped on to the constructs of normalization process theory (NPT) to consider the ways in which sense was made of the work of implementing and integrating the HRSS. The NPT analysis demonstrated a lack of commitment to, and engagement with, the HRSS on the part of patients, whilst the commitment of doctors and practice staff was to some extent mitigated by concerns about issues of governance and consent, particularly in relation to downloading electronic patient records with associated identifiers. Although the CPRD is presented as a benign, bureaucratic process, perceptions by patients and staff of inherent contradictions with centrally held values of information governance and consent in downloading and linking electronic patient records for research remains a barrier to implementation. It is likely that conclusions reached about the problems of balancing the contradictions inherent in sharing what can be perceived as a private resource for the public good are globally transferrable.

  4. Impact of patients' access to medical records in occupational medicine.

    Science.gov (United States)

    Krakov, A; Kabaha, N; Azuri, J; Moshe, S

    2018-04-14

    Information technologies offer new ways to engage with patients regarding their health, but no studies have been done in occupational health services (OHS). To examine the advantages and disadvantages of providing written and oral medical information to patients in OHS. In this cross-sectional study, data were retrieved from patients visiting four different OHS during 2014-15 for a fitness for work evaluation. We built a semi-quantitative satisfaction questionnaire, with responses ranging on a Likert scale of 1-5 from very dissatisfied (1) to very satisfied (5). There were 287 questionnaires available for analysis. The number of patients who received detailed oral and written information, which included an explanation of their health condition and of the occupational physician's (OP's) decision, was higher in clinics 1 and 3 compared to clinics 2 and 4 (48 and 38% compared to 21 and 31% respectively, P < 0.05). When patients were provided with detailed oral and written information, they declared having a better understanding (4.3 and 4.4 compared to 3.8 respectively, P < 0.001), a higher level of confidence in their OP (4.4 and 4.3 compared to 3.7 and 4 respectively, P < 0.001), a higher level of satisfaction (4.3 and 4.4 compared to 3.8 respectively, P < 0.001) and a higher sense of control and ability to correct the record (1.8 compared to 1.4 respectively, P < 0.01), compared to patients who received partial information. We recommend sharing detailed oral and written medical information with patients in OHS.

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

    Science.gov (United States)

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

    2015-08-01

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

  6. Inadequate recording of alcohol-drinking, tobacco-smoking and discharge diagnosis in medical in-patients: failure to recognize risks including drug interactions.

    Science.gov (United States)

    Bairstow, B M; Burke, V; Beilin, L J; Deutscher, C

    1993-11-01

    The records of 62 men and 43 women, 14-88 years old, admitted to general medical wards in a public teaching hospital during 1991 were examined for discharge medications and for the recording of alcohol-drinking, tobacco-smoking and discharge diagnosis. Drinking and smoking status was unrecorded in 22.9% and 21.9% of patients respectively. Twenty-four patients had 31 potential drug interactions which were related to the number of drugs prescribed and to drinking alcohol; 10.5% of the patients had interactions involving alcohol and 2.9% tobacco. Six patients received relatively or absolutely contraindicated drugs, including one asthmatic given two beta-blockers. The drugs prescribed indicated that some patients had conditions such as gastro-oesophageal disorders, diabetes and obstructive airways disease which had not been recorded. Inadequate recording of diagnoses, alcohol and smoking status creates risks to patients and may cause opportunities for preventive care to be missed. This study provides the basis for the development of undergraduate and postgraduate education programmes to address these issues and so decrease risks to patients which arise from inadequate recording practices. Incomplete diagnoses also adversely affect hospital funding where this depends on case-mix diagnostic groups. Quality assurance programmes and other strategies are being implemented to improve medical recording and prescribing habits.

  7. Attitudes of pregnant women towards personally controlled electronic, hospital-held, and patient-held medical record systems: a survey study.

    Science.gov (United States)

    Quinlivan, Julie A; Lyons, Sarah; Petersen, Rodney W

    2014-09-01

    On July 1, 2012 the Australian Government launched the personally controlled electronic health record (PCEHR). This article surveys obstetric patients about their medical record preferences and identifies barriers to adoption of the PCEHR. A survey study was conducted of antenatal patients attending a large Australian metropolitan hospital. Consecutive patients completed questionnaires during the launch phase of the PCEHR system. Quantitative and qualitative data were collected on demographics, computer access and familiarity, preference for medical record system, and perceived benefits and concerns. Of 528 women eligible to participate, 474 completed the survey (89.8%). Respondents had high levels of home access to a computer (90.5%) and the Internet (87.1%) and were familiar with using computers in daily life (median Likert scale of 9 out of 10). Despite this, respondents preferred hospital-held paper records, and only one-third preferred a PCEHR; the remainder preferred patient-held records. Compared with hospital-held paper records, respondents felt a PCEHR would reduce the risk of lost records (padvantages and disadvantages with the PCEHR, although the majority still prefer existing record systems. To increase uptake, confidentiality, privacy, and control concerns need to be addressed.

  8. 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.

  9. Overcoming structural constraints to patient utilization of electronic medical records: a critical review and proposal for an evaluation framework.

    Science.gov (United States)

    Winkelman, Warren J; Leonard, Kevin J

    2004-01-01

    There are constraints embedded in medical record structure that limit use by patients in self-directed disease management. Through systematic review of the literature from a critical perspective, four characteristics that either enhance or mitigate the influence of medical record structure on patient utilization of an electronic patient record (EPR) system have been identified: environmental pressures, physician centeredness, collaborative organizational culture, and patient centeredness. An evaluation framework is proposed for use when considering adaptation of existing EPR systems for online patient access. Exemplars of patient-accessible EPR systems from the literature are evaluated utilizing the framework. From this study, it appears that traditional information system research and development methods may not wholly capture many pertinent social issues that arise when expanding access of EPR systems to patients. Critically rooted methods such as action research can directly inform development strategies so that these systems may positively influence health outcomes.

  10. A prototype of a computerized patient record.

    Science.gov (United States)

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

    1995-01-01

    Computerized medical record systems (CPRS) should present user and problem oriented views of the patient file. Problem lists, clinical course, medication profiles and results of examinations have to be recorded in a computerized patient record. Patient review screens should give a synopsis of the patient data to inform whenever the patient record is opened. Several different types of data have to be stored in a patient record. Qualitative and quantitative measurements, narratives and images are such examples. Therefore, a CPR must also be able to handle these different data types. New methods and concepts appear frequently in medicine. Thus a CPRS must be flexible enough to cope with coming demands. We developed a prototype of a computer based patient record with a graphical user interface on a SUN workstation. The basis of the system are a dynamic data dictionary, an interpreter language and a large set of basic functions. This approach gives optimal flexibility to the system. A lot of different data types are already supported. Extensions are easily possible. There is also almost no limit concerning the number of medical concepts that can be handled by our prototype. Several applications were built on this platform. Some of them are presented to exemplify the patient and problem oriented handling of the CPR.

  11. [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.

  12. Medical Archive Recording System (MARS)

    OpenAIRE

    Mohammad Reza Tajvidi

    2007-01-01

    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...

  13. Increased patient communication using a process supplementing an electronic medical record.

    Science.gov (United States)

    Garvey, Thomas D; Evensen, Ann E

    2015-02-01

    Importance: Patients with cervical cytology abnormalities may require surveillance for many years, which increases the risk of management error, especially in clinics with multiple managing clinicians. National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) certification requires tracking of abnormal results and communicating effectively with patients. The purpose of this study was to determine whether a computer-based tracking system that is not embedded in the electronic medical record improves (1) accurate and timely communication of results and (2) patient adherence to follow-up recommendations. Design: Pre/post study using data from 2005-2012. Intervention implemented in 2008. Data collected via chart review for at least 18 months after index result. Participants: Pre-intervention: all women (N = 72) with first abnormal cytology result from 2005-2007. Post-intervention: all women (N = 128) with first abnormal cytology result from 2008-2010. Patients were seen at a suburban, university-affiliated, family medicine residency clinic. Intervention: Tracking spreadsheet reviewed monthly with reminders generated for patients not in compliance with recommendations. Main Outcome and Measures: (1) rates of accurate and timely communication of results and (2) rates of patient adherence to follow-up recommendations. Intervention decreased absent or erroneous communication from clinician to patient (6.4% pre- vs 1.6% post-intervention [P = 0.04]), but did not increase patient adherence to follow-up recommendations (76.1% pre- vs 78.0% post-intervention [ P= 0.78]). Use of a spreadsheet tracking system improved communication of abnormal results to patients, but did not significantly improve patient adherence to recommended care. Although the tracking system complies with NCQA PCMH requirements, it was insufficient to make meaningful improvements in patient-oriented outcomes.

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

    Science.gov (United States)

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

    2014-07-01

    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 during day, evening and night time. 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-defined checklist based on Danish standards for admission medical records. The time of dictation for the medical record was registered. A total of 1,183 errors were found in 778 admission medical records made during day- and evening time, and 322 errors in 222 admission medical records from night time shifts. No significant overall difference in error was found in the admission medical records when day and evening values were compared to night values. Subgroup analyses made for all four diagnoses showed no difference in day and evening values compared with night time values. Night time deterioration was not seen in the quality of the medical records.

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

    Science.gov (United States)

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

    2013-01-01

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

  16. Benefit-risk of Patients' Online Access to their Medical Records: Consensus Exercise of an International Expert Group.

    Science.gov (United States)

    Liyanage, Harshana; Liaw, Siaw-Teng; Konstantara, Emmanouela; Mold, Freda; Schreiber, Richard; Kuziemsky, Craig; Terry, Amanda L; de Lusignan, Simon

    2018-04-22

    Patients' access to their computerised medical records (CMRs) is a legal right in many countries. However, little is reported about the benefit-risk associated with patients' online access to their CMRs.  To conduct a consensus exercise to assess the impact of patients' online access to their CMRs on the quality of care as defined in six domains by the Institute of Medicine (IoM), now the National Academy of Medicine (NAM).  A five-round Delphi study was conducted. Round One explored experts' (n = 37) viewpoints on providing patients with access to their CMRs. Round Two rated the appropriateness of statements arising from Round One (n = 16). The third round was an online panel discussion of findings (n = 13) with the members of both the International Medical Informatics Association and the European Federation of Medical Informatics Primary Health Care Informatics Working Groups. Two additional rounds, a survey of the revised consensus statements and an online workshop, were carried out to further refine consensus statements.  Thirty-seven responses from Round One were used as a basis to initially develop 15 statements which were categorised using IoM's domains of care quality. The experts agreed that providing patients online access to their CMRs for bookings, results, and prescriptions increased efficiency and improved the quality of medical records. Experts also anticipated that patients would proactively use their online access to share data with different health care providers, including emergencies. However, experts differed on whether access to limited or summary data was more useful to patients than accessing their complete records. They thought online access would change recording practice, but they were unclear about the benefit-risk of high and onerous levels of security. The 5-round process, finally, produced 16 consensus statements.  Patients' online access to their CMRs should be part of all CMR systems. It improves the process

  17. Providing a complete online multimedia patient record.

    Science.gov (United States)

    Dayhoff, R. E.; Kuzmak, P. M.; Kirin, G.; Frank, S.

    1999-01-01

    Seamless integration of all types of patient data is a critical feature for clinical workstation software. The Dept. of Veterans Affairs has developed a multimedia online patient record that includes traditional medical chart information as well as a wide variety of medical images from specialties such as cardiology, pulmonary and gastrointestinal medicine, pathology, radiology, hematology, and nuclear medicine. This online patient record can present data in ways not possible with a paper chart or other physical media. Obtaining a critical mass of information online is essential to achieve the maximum benefits from an integrated patient record system. Images Figure 1 Figure 2 PMID:10566357

  18. 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.

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

    Directory of Open Access Journals (Sweden)

    Moniz Linda

    2010-10-01

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

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

    Science.gov (United States)

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

    2010-10-14

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

  1. [Introduction of computerized anesthesia-recording systems and construction of comprehensive medical information network for patients undergoing surgery in the University of Tokyo Hospital].

    Science.gov (United States)

    Kitamura, Takayuki; Hoshimoto, Hiroyuki; Yamada, Yoshitsugu

    2009-10-01

    The computerized anesthesia-recording systems are expensive and the introduction of the systems takes time and requires huge effort. Generally speaking, the efficacy of the computerized anesthesia-recording systems on the anesthetic managements is focused on the ability to automatically input data from the monitors to the anesthetic records, and tends to be underestimated. However, once the computerized anesthesia-recording systems are integrated into the medical information network, several features, which definitely contribute to improve the quality of the anesthetic management, can be developed; for example, to prevent misidentification of patients, to prevent mistakes related to blood transfusion, and to protect patients' personal information. Here we describe our experiences of the introduction of the computerized anesthesia-recording systems and the construction of the comprehensive medical information network for patients undergoing surgery in The University of Tokyo Hospital. We also discuss possible efficacy of the comprehensive medical information network for patients during surgery under anesthetic managements.

  2. Quality and correlates of medical record documentation in the ambulatory care setting

    Directory of Open Access Journals (Sweden)

    Simon Steven R

    2002-12-01

    Full Text Available Abstract Background Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record. Methods We reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care. Results Among internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 – 2.83 but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 – 0.75. Conclusions Medical record documentation varied depending on the measure, with room for improvement in most domains. A variety of

  3. 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...

  4. Data-mining of medication records to improve asthma management.

    Science.gov (United States)

    Bereznicki, Bonnie J; Peterson, Gregory M; Jackson, Shane L; Walters, E Haydn; Fitzmaurice, Kimbra D; Gee, Peter R

    2008-07-07

    To use community pharmacy medication records to identify patients whose asthma may not be well managed and then implement and evaluate a multidisciplinary educational intervention to improve asthma management. We used a multisite controlled study design. Forty-two pharmacies throughout Tasmania ran a software application that "data-mined" medication records, generating a list of patients who had received three or more canisters of inhaled short-acting beta(2)-agonists in the preceding 6 months. The patients identified were allocated to an intervention or control group. Pre-intervention data were collected for the period May to November 2006 and post-intervention data for the period December 2006 to May 2007. Intervention patients were contacted by the community pharmacist via mail, and were sent educational material and a letter encouraging them to see their general practitioner for an asthma management review. Pharmacists were blinded to the control patients' identities until the end of the post-intervention period. Dispensing ratio of preventer medication (inhaled corticosteroids [ICSs]) to reliever medication (inhaled short-acting beta(2)-agonists). Thirty-five pharmacies completed the study, providing 702 intervention and 849 control patients. The intervention resulted in a threefold increase in the preventer-to-reliever ratio in the intervention group compared with the control group (P < 0.01) and a higher proportion of patients in the intervention group using ICS therapy than in the control group (P < 0.01). Community pharmacy medication records can be effectively used to identify patients with suboptimal asthma management, who can then be referred to their GP for review. The intervention should be trialled on a national scale to determine the effects on clinical, social, emotional and economic outcomes for people in the Australian community, with a longer follow-up to determine sustainability of the improvements noted.

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

    Science.gov (United States)

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

    1992-12-01

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

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

    Science.gov (United States)

    Chen, Wei; Shih, Chien-Chou

    2012-02-01

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

  7. 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.

  8. 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.

  9. 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

  10. [The global medical record + (DMG+), tool for prevention in first line care].

    Science.gov (United States)

    Schetgen, M

    2012-09-01

    The "global medical record +" can be offered to all 45 to 75 year-old patients in the form of a prevention module within the global medical record and which the general practitioner and the patient will regularly update. It will include in particular an assessment of cardiovascular risk, cervical, breast and colon cancer screening, a check of main adult vaccinations, as well as a primary prevention section focused on smoking, alcohol consumption and various hygiene and dietary measures. The inclusion of this module in a computerized medical record will make it more efficient and will lighten the practitioner's workload.

  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. Minimal impact of an electronic medical records system.

    Science.gov (United States)

    Tall, Jill M; Hurd, Marie; Gifford, Thomas

    2015-05-01

    Electronic medical records (EMRs) implementation in hospitals and emergency departments (EDs) is becoming increasingly more common. The purpose of this study was to determine the impact of an EMR system on patient-related factors that correlate to ED workflow efficiency. A retrospective chart review assessed monthly census reports of all patients who registered and were treated to disposition during conversion from paper charts to an EMR system. The primary outcome measurement was an analysis of the time of registration to discharge or total ED length of stay as well as rate of those who left without being seen, eloped, or left against medical advice. These data were recorded from 3 periods, for 18 months: before installation of the EMR system (pre-EMR), during acclimation to the EMR, and post acclimation (post-EMR). A total of 61626 individual patient records were collected and analyzed. The total ED length of stay across all patient subtypes was not significantly affected by the installation of the hospital-wide EMR system (P = .481); however, a significant decrease was found for patients who were admitted to the hospital from the ED (P .25). Installation of a hospital-wide EMR system had minimal impact on workflow efficiency parameters in an ED. Copyright © 2015 Elsevier Inc. All rights reserved.

  13. IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety.

    Science.gov (United States)

    Caron, Alexandre; Chazard, Emmanuel; Muller, Joris; Perichon, Renaud; Ferret, Laurie; Koutkias, Vassilis; Beuscart, Régis; Beuscart, Jean-Baptiste; Ficheur, Grégoire

    2017-03-01

    The significant risk of adverse events following medical procedures supports a clinical epidemiological approach based on the analyses of collections of electronic medical records. Data analytical tools might help clinical epidemiologists develop more appropriate case-crossover designs for monitoring patient safety. To develop and assess the methodological quality of an interactive tool for use by clinical epidemiologists to systematically design case-crossover analyses of large electronic medical records databases. We developed IT-CARES, an analytical tool implementing case-crossover design, to explore the association between exposures and outcomes. The exposures and outcomes are defined by clinical epidemiologists via lists of codes entered via a user interface screen. We tested IT-CARES on data from the French national inpatient stay database, which documents diagnoses and medical procedures for 170 million inpatient stays between 2007 and 2013. We compared the results of our analysis with reference data from the literature on thromboembolic risk after delivery and bleeding risk after total hip replacement. IT-CARES provides a user interface with 3 columns: (i) the outcome criteria in the left-hand column, (ii) the exposure criteria in the right-hand column, and (iii) the estimated risk (odds ratios, presented in both graphical and tabular formats) in the middle column. The estimated odds ratios were consistent with the reference literature data. IT-CARES may enhance patient safety by facilitating clinical epidemiological studies of adverse events following medical procedures. The tool's usability must be evaluated and improved in further research. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association.

  14. 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.

  15. HyPR Device: Mobile Support for Hybrid Patient Records

    DEFF Research Database (Denmark)

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

    2014-01-01

    The patient record is one of the central artifacts in medical work that is used to organize, communicate and coordinate important information related to patient care. In many hospitals a double record consisting of an electronic and paper part is maintained. This practice introduces a number of c......PR device decreases configuration work, supports mobility in clinical work and increases awareness on patient data.......The patient record is one of the central artifacts in medical work that is used to organize, communicate and coordinate important information related to patient care. In many hospitals a double record consisting of an electronic and paper part is maintained. This practice introduces a number...... introduce the HyPR Device, a device that merges the paper and electronic patient record into one system. We provide results from a clinical simulation with eight clinicians and discuss the functional, design and infrastructural requirements of such hybrid patient records. Our study suggests that the Hy...

  16. 42 CFR 482.24 - Condition of participation: Medical record services.

    Science.gov (United States)

    2010-10-01

    ... anesthesia services. (B) An updated examination of the patient, including any changes in the patient's... practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory...

  17. 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

  18. Medical narratives and patient analogs: the ethical implications of electronic patient records.

    Science.gov (United States)

    Kluge, E H

    1999-12-01

    An electronic patient record consists of electronically stored data about a specific patient. It therefore constitutes a data-space. The data may be combined into a patient profile which is relative to a particular specialty as well as phenomenologically unique to the specific professional who constructs the profile. Further, a diagnosis may be interpreted as a path taken by a health care professional with a certain specialty through the data-space relative to the patient profile constructed by that professional. This way of looking at electronic patient records entails certain ethical implications about privacy and accessibility. However, it also permits the construction of artificial intelligence and competence algorithms for health care professionals relative to their specialties.

  19. Reducing and Sustaining Duplicate Medical Record Creation by Usability Testing and System Redesign.

    Science.gov (United States)

    Khunlertkit, Adjhaporn; Dorissaint, Leonard; Chen, Allen; Paine, Lori; Pronovost, Peter J

    2017-10-25

    Duplicate medical record creation is a common and consequential health care systems error often caused by poor search system usability and inappropriate user training. We conducted two phases of scenario-based usability testing with patient registrars working in areas at risk of generating duplicate medical records. Phase 1 evaluated the existing search system, which led to system redesigns. Phase 2 tested the redesigned system to mitigate potential errors before health system-wide implementation. To evaluate system effectiveness, we compared the monthly potential duplicate medical record rates for preimplementation and postimplementation months. The existing system could not effectively handle a misspelling, which led to failed search and duplicate medical record creation. Using the existing system, 96% of registrars found commonly spelled patient names whereas only 69% successfully found complicated names. Registrars lacked knowledge and usage of a phonetic matching function to assist in misspelling. The new system consistently captured the correct patient regardless of misspelling, but search returned more potential matches, resulting in, on average, 4 seconds longer to select common names. Potential monthly duplicate medical record rate reduced by 38%, from 4% to 2.3% after implementation of the new system, and has sustained at an average of 2.5% for 2 years. Usability testing was an effective method to reveal problems and aid system redesign to deliver a more user friendly system, hence reducing the potential for medical record duplication. Greater standards for usability would ensure that these improvements can be realized before rather than after exposing patients to risks.

  20. Audit of Medical Records of Shahid Madani Hospital

    Directory of Open Access Journals (Sweden)

    Mohammad farough-khosravi

    2016-12-01

    Full Text Available Background and Objectives: Evaluation of the quality of services and provided cares through comparing them with existing standards in order to identify and prioritize problems and trying to fix them are important steps in the audit of clinical functions. This study aimed to improve the quality of performance of medical records registrations about patients admitted to hospital Shahid Madani and deals with the audit of records listed them. Material and Methods: To perform this study, data were collected using researcher checklist. Target data of 30 medical records were gathered. We used software package of Mini Tab and SPSS to develop process statistical control charts and for statistical analysis of data, respectively. Results: By plotting control charts, we determined three specific reasons in the ADMISSION AND DISCHARGE SUMMARY SHEET, four specific reasons in the SUMMARY SHEET, and three specific reasons in CONSULTATION REQUEST SHEET. The lack of the standard form (on-delivered copies of a summary form “with 90%”, lack of the main form in patient's clinical record “with 83.3%”, lack of the patient's procedure “with 73.3%”are ranked as the most defects in SUMMARY SHEET. In the CONSULTATION REQUEST SHEET, failure to comply with doctor's stamp and signature standard with “20%” has highest percentage of defects. In the ADMISSION AND DISCHARGE SUMMARY SHEET nonconformity of standard records, patient's duration of stay “100%”, coding of diseases based on ICD"100%", recording of patient number based on signs and symptoms "93.3%", usingthe abbreviations to record the recognitions "93.3%" have highest percentage of defects respectively. Conclusion: Based on the results of this study and noting that studied standards of process statistical control charts are in the range of control, the quality of standards and the documentations of  the records

  1. HOSPITAL INFORMATION SYSTEMS: A STUDY OF ELECTRONIC PATIENT RECORDS

    Directory of Open Access Journals (Sweden)

    Pedro Luiz Cortês

    2011-05-01

    Full Text Available The importance of patient records, also known as medical records, is related to different needs and objectives, as they constitute permanent documents on the health of patients. With the advancement of information technologies and systems, patient records can be stored in databases, resulting in a positive impact on patient care. Based on these considerations, a research question that arises is “what are the benefits and problems that can be seen with the use of electronic versions of medical records?” This question leads to the formulation of the following hypothesis: although problems can be identified during the process of using electronic record systems, the benefits outweigh the difficulties, thereby justifying their use. To respond to the question and test the presented hypothesis, a research study was developed with users of the same electronic record system, consisting of doctors, nurses, and administrative personnel in three hospitals located in the city of São Paulo, Brazil. The results show that, despite some problems in their usage, the benefits of electronic patient records outweigh possible disadvantages.

  2. Dynamic consent: a possible solution to improve patient confidence and trust in how electronic patient records are used in medical research.

    Science.gov (United States)

    Williams, Hawys; Spencer, Karen; Sanders, Caroline; Lund, David; Whitley, Edgar A; Kaye, Jane; Dixon, William G

    2015-01-13

    With one million people treated every 36 hours, routinely collected UK National Health Service (NHS) health data has huge potential for medical research. Advances in data acquisition from electronic patient records (EPRs) means such data are increasingly digital and can be anonymised for research purposes. NHS England's care.data initiative recently sought to increase the amount and availability of such data. However, controversy and uncertainty following the care.data public awareness campaign led to a delay in rollout, indicating that the success of EPR data for medical research may be threatened by a loss of patient and public trust. The sharing of sensitive health care data can only be done through maintaining such trust in a constantly evolving ethicolegal and political landscape. We propose that a dynamic consent model, whereby patients can electronically control consent through time and receive information about the uses of their data, provides a transparent, flexible, and user-friendly means to maintain public trust. This could leverage the huge potential of the EPR for medical research and, ultimately, patient and societal benefit.

  3. Sustains--direct access for the patient to the medical record over the Internet.

    Science.gov (United States)

    Eklund, Benny; Joustra-Enquist, Ingrid

    2004-01-01

    The basic idea of Sustains III is to emulate the Internet banking for Health Care. Instead of an "Internet Bank Account" the user has a "Health Care Account". The user logs in using a One Time Password which is sent to the user's mobile phone as an SMS, three seconds after the PIN code is entered. Thus personal information can be transferred both ways in a secure way, with acceptable privacy. The user can then explore the medical record in detail. Also get full and complete list of prescriptions, lab-result etc. It's also an easy way of exchange written information between the doctor and the patient. So far Sustains has showed that patients are very satisfied and is also beneficial for the physicians.

  4. Dental management of medically compromised patients

    Directory of Open Access Journals (Sweden)

    Sherly Horax

    2016-06-01

    Full Text Available These days, treatment in dentistry is no longer for patient without complication, but also for patient with bad medical record. With correct treatment management in handling medical condition of patient, not only for dental treatment but also their systematic disease, all the dental staff also can improve for the better quality of life of the patient. Patient with medical compromised start to realize that  keeping good oral hygiene is so important for their lives, therefore dental staff need to improve their science and technology and also for facing patient with medical compromised. This article will discuss and suggest various treatment consideration and protocol for the patient of with medical compromised.

  5. 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.

  6. Collaborative Affordances of Medical Records

    DEFF Research Database (Denmark)

    Bardram, Jakob Eyvind; Houben, Steven

    2017-01-01

    by Sellen and Harper (2003) on the affordances of physical paper. Sellen and Harper describe how the physical properties of paper affords easy reading, navigation, mark-up, and writing, but focuses, we argue, mainly on individual use of paper and digital technology. As an extension to this, Collaborative...... Affordances; being portable across patient wards and the entire hospital, by providing collocated access, by providing a shared overview of medical data, and by giving clinicians ways to maintain mutual awareness. We then discuss how the concept of Collaborative Affordances can be used in the design of new...... technology by providing a design study of a ‘Hybrid Patient Record’ (HyPR), which is designed to seamlessly blend and integrate paper-based with electronic patient records....

  7. Giving rheumatology patients online home access to their electronic medical record (EMR): advantages, drawbacks and preconditions according to care providers

    NARCIS (Netherlands)

    van der Vaart, R.; Drossaert, Constance H.C.; Taal, Erik; van de Laar, Mart 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.

  8. [Electronic patient record as the tool for better patient safety].

    Science.gov (United States)

    Schneider, Henning

    2015-01-01

    Recent studies indicate again that there is a deficit in the use of electronic health records (EHR) in German hospitals. Despite good arguments in favour of their use, such as the rapid availability of data, German hospitals shy away from a wider implementation. The reason is the high cost of installing and maintaining the EHRs, for the benefit is difficult to evaluate in monetary terms for the hospital. Even if a benefit can be shown it is not necessarily evident within the hospital, but manifests itself only in the health system outside. Many hospitals only manage to partly implement EHR resulting in increased documentation requirements which reverse their positive effect.In the United States, electronic medical records are also viewed in light of their positive impact on patient safety. In particular, electronic medication systems prove the benefits they can provide in the context of patient safety. As a result, financing systems have been created to promote the digitalisation of hospitals in the United States. This has led to a large increase in the use of IT systems in the United States in recent years. The Universitätsklinikum Eppendorf (UKE) introduced electronic patient records in 2009. The benefits, in particular as regards patient safety, are numerous and there are many examples to illustrate this position. These positive results are intended to demonstrate the important role EHR play in hospitals. A financing system of the ailing IT landscape based on the American model is urgently needed to benefit-especially in terms of patient safety-from electronic medical records in the hospital.

  9. Predicting healthcare trajectories from medical records: A deep learning approach.

    Science.gov (United States)

    Pham, Trang; Tran, Truyen; Phung, Dinh; Venkatesh, Svetha

    2017-05-01

    Personalized predictive medicine necessitates the modeling of patient illness and care processes, which inherently have long-term temporal dependencies. Healthcare observations, stored in electronic medical records are episodic and irregular in time. We introduce DeepCare, an end-to-end deep dynamic neural network that reads medical records, stores previous illness history, infers current illness states and predicts future medical outcomes. At the data level, DeepCare represents care episodes as vectors and models patient health state trajectories by the memory of historical records. Built on Long Short-Term Memory (LSTM), DeepCare introduces methods to handle irregularly timed events by moderating the forgetting and consolidation of memory. DeepCare also explicitly models medical interventions that change the course of illness and shape future medical risk. Moving up to the health state level, historical and present health states are then aggregated through multiscale temporal pooling, before passing through a neural network that estimates future outcomes. We demonstrate the efficacy of DeepCare for disease progression modeling, intervention recommendation, and future risk prediction. On two important cohorts with heavy social and economic burden - diabetes and mental health - the results show improved prediction accuracy. Copyright © 2017 Elsevier Inc. All rights reserved.

  10. The Next Generation Precision Medical Record - A Framework for Integrating Genomes and Wearable Sensors with Medical Records

    OpenAIRE

    Batra, Prag; Singh, Enakshi; Bog, Anja; Wright, Mark; Ashley, Euan; Waggott, Daryl

    2016-01-01

    Current medical records are rigid with regards to emerging big biomedical data. Examples of poorly integrated big data that already exist in clinical practice include whole genome sequencing and wearable sensors for real time monitoring. Genome sequencing enables conventional diagnostic interrogation and forms the fundamental baseline for precision health throughout a patients lifetime. Mobile sensors enable tailored monitoring regimes for both reducing risk through precision health intervent...

  11. Evaluation of the process of recording patient education, consistency of record-keeping with perception, and patient satisfaction after implementing clinical supervision: An embedded evaluation

    Directory of Open Access Journals (Sweden)

    Khorasani Parvaneh

    2016-08-01

    Full Text Available Background and Objective: Currently, patient education has been considered in medical centers. Clinical provision, which is one of the legal tools with training-support dimensions, can evaluate the consistency between the implemented procedures and the planned ones. This study aimed to evaluate the process of recording patient education, consistency of record-keeping with perception, and patient satisfaction after implementing clinical supervision. Materials and Methods: This longitudinal, embedded study was conducted during 2013-2015 in three stages of designing, implementation, and evaluation of the supervision program using randomized convenience sampling on 786 monitoring units (medical records of patients being discharged at Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. In the designing stage, the checklists for supervision of recording patient education and consistency of patient perception with the recorded trainings and the patient satisfaction questionnaire were designed and their valididty and reliability were established. In the implementation stage, structure of the monitoring program was designed with the cooperation of eight supervisors. During 12 months, 2333 checklists and questionnaires were completed at the time of hospital discharge in the evaluation stage. Data analysis was performed in SPSS, version 18, using One-way ANOVA. Results: After 12 months of embedded evaluation, the mean score of recording patient education was 88.5±21.75, and the mean scores of patient satisfaction with the training process and consistency between patients’ perception and the recorded trainings were 47.17±21.48 and 73±25.13, respectively. The mean scores of recording patient training and consistency between patients’ perception and the recorded trainings had an increasing trend (P<0.001, while the mean score of patient satisfaction reduced (P<0.001. Conclusion: The results of clinical supervision during

  12. Using Electronic Patient Records to Discover Disease Correlations and Stratify Patient Cohorts

    DEFF Research Database (Denmark)

    Roque, Francisco S.; Jensen, Peter B.; Schmock, Henriette

    2011-01-01

    Electronic patient records remain a rather unexplored, but potentially rich data source for discovering correlations between diseases. We describe a general approach for gathering phenotypic descriptions of patients from medical records in a systematic and non-cohort dependent manner. By extracting...... phenotype information from the free-text in such records we demonstrate that we can extend the information contained in the structured record data, and use it for producing fine-grained patient stratification and disease co-occurrence statistics. The approach uses a dictionary based on the International...

  13. 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

  14. Effect of teaching and checklist implementation on accuracy of medication history recording at hospital admission.

    Science.gov (United States)

    Lea, Marianne; Barstad, Ingeborg; Mathiesen, Liv; Mowe, Morten; Molden, Espen

    2016-02-01

    Medication discrepancies at hospital admission is an extensive problem and knowledge is limited regarding improvement strategies. To investigate the effect of teaching and checklist implementation on accuracy of medication history recording during hospitalization. Patients admitted to an internal medicine ward were prospectively included in two consecutive periods. Between the periods, non-mandatory teaching lessons were provided and a checklist assisting medication history recording implemented. Discrepancies between the recorded medications at admission and the patient's actual drug use, as revealed by pharmacist-conducted medication reconciliation, were compared between the periods. The primary endpoint was difference between the periods in proportion of patients with minimum one discrepancy. Difference in median number of discrepancies was included as a secondary endpoint. 56 and 119 patients were included in period 1 (P1) and period 2 (P2), respectively. There was no significant difference in proportion of patients with minimum one discrepancy in P2 (68.9 %) versus P1 (76.8 %, p = 0.36), but a tendency of lower median number of discrepancies was observed in P2 than P1, i.e. 1 and 2, respectively (p = 0.087). More powerful strategies than non-mandatory teaching activities and checklist implementation are required to achieve sufficient improvements in medication history recording during hospitalization.

  15. [Problem list in computer-based patient records].

    Science.gov (United States)

    Ludwig, C A

    1997-01-14

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

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

    Science.gov (United States)

    Bremond-Gignac, Dominique; Lewandowski, Elisabeth; Copin, Henri

    2015-01-01

    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. 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. 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. 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. 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.

  17. 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

  18. Comparing a medical records-based and a claims-based index for measuring comorbidity in patients with lung or colon cancer.

    Science.gov (United States)

    Kehl, Kenneth L; Lamont, Elizabeth B; McNeil, Barbara J; Bozeman, Samuel R; Kelley, Michael J; Keating, Nancy L

    2015-05-01

    Ascertaining comorbid conditions in cancer patients is important for research and clinical quality measurement, and is particularly important for understanding care and outcomes for older patients and those with multi-morbidity. We compared the medical records-based ACE-27 index and the claims-based Charlson index in predicting receipt of therapy and survival for lung and colon cancer patients. We calculated the Charlson index using administrative data and the ACE-27 score using medical records for Veterans Affairs patients diagnosed with stage I/II non-small cell lung or stage III colon cancer from January 2003 to December 2004. We compared the proportion of patients identified by each index as having any comorbidity. We used multivariable logistic regression to ascertain the predictive power of each index regarding delivery of guideline-recommended therapies and two-year survival, comparing the c-statistic and the Akaike information criterion (AIC). Overall, 97.2% of lung and 90.9% of colon cancer patients had any comorbidity according to the ACE-27 index, versus 59.5% and 49.7%, respectively, according to the Charlson. Multivariable models including the ACE-27 index outperformed Charlson-based models when assessing receipt of guideline-recommended therapies, with higher c-statistics and lower AICs. Neither index was clearly superior in prediction of two-year survival. The ACE-27 index measured using medical records captured more comorbidity and outperformed the Charlson index measured using administrative data for predicting receipt of guideline-recommended therapies, demonstrating the potential value of more detailed comorbidity data. However, the two indices had relatively similar performance when predicting survival. Copyright © 2015 Elsevier Inc. All rights reserved.

  19. Management of stinging insect hypersensitivity: a 5-year retrospective medical record review.

    Science.gov (United States)

    Johnson, Thomas; Dietrich, Jeffrey; Hagan, Larry

    2006-08-01

    The Joint Task Force on Practice Parameters for Allergy and Immunology recommends that patients with a history of a systemic reaction to an insect sting be educated on ways to avoid insect stings, carry injectable epinephrine for emergency self-treatment, undergo specific IgE testing for stinging insect sensitivity, and be considered for immunotherapy. To review frontline providers' documented care and recommendations for imported fire ant and flying insect hypersensitivity reactions. A retrospective medical record review was performed of emergency department and primary care clinic visits between November 1, 1999, and November 30, 2004. Using International Classification of Diseases, Ninth Revision, codes, medical records were selected for review to identify patients with potential insect hypersensitivity. A total of 769 medical records from patients who experienced an insect sting were reviewed. Of 120 patients with a systemic reaction, 66 (55.0%) received a prescription for injectable epinephrine, and 14 (11.7%) were given information regarding avoidance of the offending insect. Forty-seven patients with systemic reactions (39.2%) were referred to an allergist. Of 28 patients who kept their appointments and underwent skin testing, 3 had negative results and 25 (89%) had positive results and were advised to start immunotherapy. Adherence to the stinging insect hypersensitivity practice parameter recommendations is poor. Many patients who have experienced a systemic reaction after an insect sting and have sought medical care are not afforded an opportunity for potentially lifesaving therapy.

  20. Maternity patients' access to their electronic medical records: use and perspectives of a patient portal.

    Science.gov (United States)

    Megan Forster, Megan; Dennison, Kerrie; Callen, Joanne; Andrew, Andrew; Westbrook, Johanna I

    Patients have been able to access clinical information from their paper-based health records for a number of years. With the advent of Electronic Medical Records (EMRs) access to this information can now be achieved online using a secure electronic patient portal. The purpose of this study was to investigate maternity patients' use and perceptions of a patient portal developed at the Mater Mothers' Hospital in Brisbane, Australia. A web-based patient portal, one of the first developed and deployed in Australia, was introduced on 26 June 2012. The portal was designed for maternity patients booked at Mater Mothers' Hospital, as an alternative to the paper-based Pregnancy Health Record. Through the portal, maternity patients are able to complete their hospital registration form online and obtain current health information about their pregnancy (via their EMR), as well as access a variety of support tools to use during their pregnancy such as tailored public health advice. A retrospective cross-sectional study design was employed. Usage statistics were extracted from the system for a one year period (1 July 2012 to 30 June 2013). Patients' perceptions of the portal were obtained using an online survey, accessible by maternity patients for two weeks in February 2013 (n=80). Descriptive statistics were employed to analyse the data. Between July 2012 and June 2013, 10,892 maternity patients were offered a patient portal account and access to their EMR. Of those 6,518 created one (60%; 6,518/10,892) and 3,104 went on to request access to their EMR (48%; 3,104/6,518). Of these, 1,751 had their access application granted by 30 June 2013. The majority of maternity patients submitted registration forms online via the patient portal (56.7%). Patients could view their EMR multiple times: there were 671 views of the EMR, 2,781 views of appointment schedules and 135 birth preferences submitted via the EMR. Eighty survey responses were received from EMR account holders, (response

  1. 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.

  2. How complete is the information on preadmission psychotropic medications in inpatients with dementia? A comparison of hospital medical records with dispensing data.

    Science.gov (United States)

    Pisa, Federica Edith; Palese, Francesca; Romanese, Federico; Barbone, Fabio; Logroscino, Giancarlo; Riedel, Oliver

    2018-06-05

    Reliable information on preadmission medications is essential for inpatients with dementia, but its quality has hardly been evaluated. We assessed the completeness of information and factors associated with incomplete recording. We compared preadmission medications recorded in hospital electronic medical records (EMRs) with community-pharmacy dispensations in hospitalizations with discharge code for dementia at the University Hospital of Udine, Italy, 2012-2014. We calculated: (a) prevalence of omissions (dispensed medication not recorded in EMRs), additions (medication recorded in EMRs not dispensed), and discrepancies (any omission or addition); (b) multivariable logistic regression odds ratio, with 95% confidence interval (95% CI), of ≥1 omission. Among 2,777 hospitalizations, 86.1% had ≥1 discrepancy for any medication (Kappa 0.10) and 33.4% for psychotropics. When psychotropics were recorded in EMR, antipsychotics were added in 71.9% (antidepressants: 29.2%, antidementia agents: 48.2%); when dispensed, antipsychotics were omitted in 54.4% (antidepressants: 52.7%, antidementia agents: 41.5%). Omissions were 92% and twice more likely in patients taking 5 to 9 and ≥10 medications (vs. 0 to 4), 17% in patients with psychiatric disturbances (vs. none), and 41% with emergency admission (vs. planned). Psychotropics, commonly used in dementia, were often incompletely recorded. To enhance information completeness, both EMRs and dispensations should be used. Copyright © 2018 John Wiley & Sons, Ltd.

  3. Customization of electronic medical record templates to improve end-user satisfaction.

    Science.gov (United States)

    Gardner, Carrie Lee; Pearce, Patricia F

    2013-03-01

    Since 2004, increasing importance has been placed on the adoption of electronic medical records by healthcare providers for documentation of patient care. Recent federal regulations have shifted the focus from adoption alone to meaningful use of an electronic medical record system. As proposed by the Technology Acceptance Model, the behavioral intention to use technology is determined by the person's attitude toward usage. The purpose of this quality improvement project was to devise and implement customized templates into an existent electronic medical record system in a single clinic and measure the satisfaction of the clinic providers with the system before and after implementation. Provider satisfaction with the electronic medical record system was evaluated prior to and following template implementation using the current version 7.0 of the Questionnaire for User Interaction Satisfaction tool. Provider comments and improvement in the Questionnaire for User Interaction Satisfaction levels of rankings following template implementation indicated a positive perspective by the providers in regard to the templates and customization of the system.

  4. Validation of a Delirium Risk Assessment Using Electronic Medical Record Information.

    Science.gov (United States)

    Rudolph, James L; Doherty, Kelly; Kelly, Brittany; Driver, Jane A; Archambault, Elizabeth

    2016-03-01

    Identifying patients at risk for delirium allows prompt application of prevention, diagnostic, and treatment strategies; but is rarely done. Once delirium develops, patients are more likely to need posthospitalization skilled care. This study developed an a priori electronic prediction rule using independent risk factors identified in a National Center of Clinical Excellence meta-analysis and validated the ability to predict delirium in 2 cohorts. Retrospective analysis followed by prospective validation. Tertiary VA Hospital in New England. A total of 27,625 medical records of hospitalized patients and 246 prospectively enrolled patients admitted to the hospital. The electronic delirium risk prediction rule was created using data obtained from the patient electronic medical record (EMR). The primary outcome, delirium, was identified 2 ways: (1) from the EMR (retrospective cohort) and (2) clinical assessment on enrollment and daily thereafter (prospective participants). We assessed discrimination of the delirium prediction rule with the C-statistic. Secondary outcomes were length of stay and discharge to rehabilitation. Retrospectively, delirium was identified in 8% of medical records (n = 2343); prospectively, delirium during hospitalization was present in 26% of participants (n = 64). In the retrospective cohort, medical record delirium was identified in 2%, 3%, 11%, and 38% of the low, intermediate, high, and very high-risk groups, respectively (C-statistic = 0.81; 95% confidence interval 0.80-0.82). Prospectively, the electronic prediction rule identified delirium in 15%, 18%, 31%, and 55% of these groups (C-statistic = 0.69; 95% confidence interval 0.61-0.77). Compared with low-risk patients, those at high- or very high delirium risk had increased length of stay (5.7 ± 5.6 vs 3.7 ± 2.7 days; P = .001) and higher rates of discharge to rehabilitation (8.9% vs 20.8%; P = .02). Automatic calculation of delirium risk using an EMR algorithm identifies patients at

  5. Perception of electronic medical records (EMRs by nursing staff in a teaching hospital in India

    Directory of Open Access Journals (Sweden)

    Naveen Kumar Pera

    2014-01-01

    Full Text Available Background: Currently, in India, many healthcare organizations and their managements appreciate the advantages of electronic medical records, but they often use them. The current push for universal health coverage in India with National Rural Health Mission (NRHM and National Urban Health Mission (NUHM helping toward healthcare reforms highlights the importance of implementing information technology as a means of cutting costs and improving efficiency in healthcare field. The quality of documentation of patient care rendered at healthcare destinations is very important to showcase the growing stature of healthcare in India. Aims: As maintaining the medical records is very important, storage and retrieval of the information is also important for future patient care. In this regard, implementation of electronic medical records in hospitals is essential. Through this study, we wanted to highlight the perceptions of healthcare personnel, who are in the core team of delivering healthcare, toward implementation of electronic medical records. Methods: A cross-sectional study was carried out among doctors (post-graduates and staff nurses. The sample size for post-graduate students and nurses was 164 and 296, respectively, in this study. The study was carried out during the period from January to June 2013, and a survey was conducted with the help of a validated, pre-tested questionnaire in a tertiary care medical college hospital in India. Results: The results showed that 75% of the study population are comfortable working with electronic medical records. They mentioned that display of diagnosis, medications, and allergies of patients on the records was most important. Their perception was that electronic medical records improve timely decision-making and patient care due to immediate access to the patient′s disease history. Conclusion: The major problems faced by nurses, as per our study, are delay in services due to dispersion of records

  6. Medical records and radiation exposure cards

    International Nuclear Information System (INIS)

    Vigan, C.

    1975-01-01

    Some ideas concerning medical records at the Ispra Centre are exposed. The approved medical practitioner has two main tasks: he must gather enough relevant information to decide on the worker's suitability and also to determine his physical condition, normal or otherwise, and he must record it with enough detail to permit comparison with findings at later examinations. for the purposes of medical records, clinical examinations and complementary investigations, a large proportion of the measurements are of course made on the critical organs. The problems of the container or physical medium receiving the information to be recorded is considered. The possibilities offered by computer techniques are discussed

  7. 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

  8. The use of nationwide on-line prescription records improves the drug history in hospitalized patients

    DEFF Research Database (Denmark)

    Glintborg, Bente; Poulsen, Henrik E; Dalhoff, Kim P

    2008-01-01

    What is already known about this subject: Structured medication interviews improve the medication history upon hospitalization. Pharmacy records are valid lists of the prescribed medications available to individual patients. In Denmark, treating doctors now have access to their patients' pharmacy...... records through a real-time online electronic database What this study adds: Omission errors are frequent among hospitalized patients despite structured drug interviews and home visits. Pharmacy records may be used to minimize patients' recall bias and improve the medication lists....

  9. Evaluation of the medical records system in an upcoming teaching hospital-a project for improvisation.

    Science.gov (United States)

    Kumar, B Deepak; Kumari, C M Vinaya; Sharada, M S; Mangala, M S

    2012-08-01

    The medical records system of an upcoming teaching hospital in a developing nation was evaluated for its accessibility, completeness, physician satisfaction, presence of any lacunae, suggestion of necessary steps for improvisation and to emphasize the importance of Medical records system in education and research work. The salient aspects of the medical records department were evaluated based on a questionnaire which was evaluated by a team of 40 participants-30 doctors, 5 personnel from Medical Records Department and 5 from staff of Hospital administration. Most of the physicians (65%) were partly satisfied with the existing medical record system. 92.5% were of the opinion that upgradation of the present system is necessary. The need of the hour in the present teaching hospital is the implementation of a hospital-wide patient registration and medical records re-engineering process in the form of electronic medical records system and regular review by the audit commission.

  10. Introduction of an automated medical record at an HMO clinic.

    Science.gov (United States)

    Churgin, P G

    1994-01-01

    In May 1993, CIGNA Healthcare of Arizona implemented a comprehensive automated medical record system in a pilot project performed at a primary care clinic in Chandler, Arizona. The system, EpicCare, operates in a client-server environment and completely replaces the paper chart in all phases of medical care. After six months of use by 10 medical providers and a 50-member staff, the system has been approved by clinicians, staff, and patients.

  11. Psychometric validation of a new measurement instrument for time-oriented patient information in electronic medical records: A questionnaire survey of physicians.

    Science.gov (United States)

    Shibuya, Akiko; Misawa, Jimpei; Maeda, Yukihiro; Ichikawa, Rie; Kamata, Michiyo; Inoue, Ryusuke; Morimoto, Tetsuji; Nakayama, Masaharu; Hishiki, Teruyoshi; Kondo, Yoshiaki

    2017-12-01

    Time is an important element in medical data. Physicians record and store information about patients' disease progress and treatment response in electronic medical records (EMRs). Because EMRs use timestamps, physicians can identify patterns over time regarding a patient's disease and treatment (eg, laboratory values and medications). However, analyses of physicians' use and satisfaction with EMRs have focused on functionality, storage, and system operation rather than the use of time-oriented information. This study aimed to understand physicians' needs regarding time-oriented patient information in EMRs in clinical practice. The reliability and validity of the items in the questionnaire were evaluated in 87 physicians at a national university hospital. Internal consistency was satisfactory (Cronbach alpha coefficient, 0.87). Four dimensions were identified in exploratory factor analysis. Correlations between the 4 dimensions supported the construct validity of the items. Scores of time-oriented patients' medical history in the 4 dimensions showed a significant association with physician age. Based on confirmatory factor analysis, associations were significant and positive (P information in EMRs, both time-oriented treatment results followed by time-oriented team information had significant positive associations. Our study suggests that 4 specific time-oriented patient information factors in EMRs are needed by physicians. Exploring physicians' needs regarding patient-specific time-oriented information may provide a better understanding of the barriers facing the adoption and use of EMRs (eg, decision-making and practice safety concerns) and lead to better acceptance of EMRs in physicians' clinical practices. © 2017 John Wiley & Sons, Ltd.

  12. Enhancing Student Empathetic Engagement, History-Taking, and Communication Skills During Electronic Medical Record Use in Patient Care.

    Science.gov (United States)

    LoSasso, Alisa Alfonsi; Lamberton, Courtney E; Sammon, Mary; Berg, Katherine T; Caruso, John W; Cass, Jonathan; Hojat, Mohammadreza

    2017-07-01

    To examine whether an intervention on proper use of electronic medical records (EMRs) in patient care could help improve medical students' empathic engagement, and to test the hypothesis that the training would reduce communication hurdles in clinical encounters. Seventy third-year medical students from the Sidney Kimmel Medical College at Thomas Jefferson University were randomly divided into intervention and control groups during their six-week pediatric clerkship in 2012-2013. The intervention group received a one-hour training session on EMR-specific communication skills, including discussion of EMR use, the SALTED mnemonic and technique (Set-up, Ask, Listen, Type, Exceptions, Documentation), and role-plays. Both groups completed the Jefferson Scale of Empathy (JSE) at the clerkship's start and end. At clerkship's end, faculty and standardized patients (SPs) rated students' empathic engagement in SP encounters, using the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE), and their history-taking and communication skills. Faculty mean ratings on the JSPPPE, history-taking skills, and communication skills were significantly higher for the intervention group than the control group. SP mean ratings on history-taking skills were significantly higher for the intervention group than the control group. Both groups' JSE mean scores increased pretest to posttest, but the changes were not significant. The intervention group's posttest JSE mean score was higher than the control group's, but the difference was not significant. The findings suggest that a simple intervention providing specialized training in EMR-specific communication can improve medical students' empathic engagement in patient care, history-taking skills, and communication skills.

  13. Do Electronic Health Records Help or Hinder Medical Education?

    OpenAIRE

    Peled, Jonathan U.; Sagher, Oren; Morrow, Jay B.; Dobbie, Alison E.

    2009-01-01

    Background to the Debate Background to the debate: Many countries worldwide are digitizing patients' medical records. In the United States, the recent economic stimulus package (?the American Recovery and Reinvestment Act of 2009?), signed into law by President Obama, includes $US17 billion in incentives for health providers to switch to electronic health records (EHRs). The package also includes $US2 billion for the development of EHR standards and best-practice guidelines. What impact will ...

  14. 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.

  15. A Primer on Endoscopic Electronic Medical Records

    OpenAIRE

    Atreja, Ashish; Rizk, Maged; Gurland, Brooke

    2010-01-01

    Endoscopic electronic medical record systems (EEMRs) are now increasingly utilized in many endoscopy centers. Modern EEMRs not only support endoscopy report generation, but often include features such as practice management tools, image and video clip management, inventory management, e-faxes to referring physicians, and database support to measure quality and patient outcomes. There are many existing software vendors offering EEMRs, and choosing a software vendor can be time consuming and co...

  16. 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.

  17. 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.

  18. Prevalence of self-reported medical conditions among dental patients

    Directory of Open Access Journals (Sweden)

    Mukhatar A Javali

    2017-01-01

    Conclusion: The results of our study found a high prevalence of medical conditions among patients seeking periodontal treatment, thereby highlighting the need to record patients' medical and dental care history in detail.

  19. Report for fiscal 2000 on electronic patient record network discussion committee. Survey on promotion of medical information use utilizing electronic patient record network; 2000 nendo denshi karute network kento iinkai hokokusho. Denshi karute network wo katsuyoshita iryo johoka no sokushin ni kansuru chosa

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2001-03-01

    Based on the movements in the most advanced IT technologies and in social system reformation in the medical and health preservation fields, discussions were given on the assignments and measures to be solved to realize the medical information network, and the secondary utilization method of the medical information and the assignments and measures in the utilization thereof. A patient record is originally a document stating the secrets of a patient for his or her medical information, and has a nature that doctors may be sued from the patient if they disclose or exchange the document. There is a large number of company owners, politicians or salaried people who would not want their diseases which they had in the past, the name of the existing disease and medical treatment to be made public. The electronic patient record network has a conflicting proposition to elevate its values by means of data re-utilization, secondary utilization and information exchange. Preparation of the database requires multilateral analyses and classifications, as well as sufficient discussions and realistic execution including the consistency with the personal information protection law, as to whether it is information that the patient wants the exchange or disclosure, or whether it is information to be exchanged or disclosed even if the patient refuses it, not speak of attention to 5W1H. (NEDO)

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

    Science.gov (United States)

    Gosman, Minna L.

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

  1. Medical Terminology of the Respiratory System. Medical Records. Instructional Unit for the Medical Transcriptionist.

    Science.gov (United States)

    Gosman, Minna L.

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

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

    Science.gov (United States)

    Gosman, Minna L.

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

  3. Using electronic patient records to discover disease correlations and stratify patient cohorts.

    Directory of Open Access Journals (Sweden)

    Francisco S Roque

    2011-08-01

    Full Text Available Electronic patient records remain a rather unexplored, but potentially rich data source for discovering correlations between diseases. We describe a general approach for gathering phenotypic descriptions of patients from medical records in a systematic and non-cohort dependent manner. By extracting phenotype information from the free-text in such records we demonstrate that we can extend the information contained in the structured record data, and use it for producing fine-grained patient stratification and disease co-occurrence statistics. The approach uses a dictionary based on the International Classification of Disease ontology and is therefore in principle language independent. As a use case we show how records from a Danish psychiatric hospital lead to the identification of disease correlations, which subsequently can be mapped to systems biology frameworks.

  4. Tolerability of central nervous system symptoms among HIV-1 infected efavirenz users: analysis of patient electronic medical record data.

    Science.gov (United States)

    Rosenblatt, Lisa; Broder, Michael S; Bentley, Tanya G K; Chang, Eunice; Reddy, Sheila R; Papoyan, Elya; Myers, Joel

    2017-08-01

    Efavirenz (EFV) is a non-nucleoside reverse transcriptase inhibitor indicated for treatment of HIV-1 infection. Despite concern over EFV tolerability in clinical trials and practice, particularly related to central nervous system (CNS) adverse events, some observational studies have shown high rates of EFV continuation at one year and low rates of CNS-related EFV substitution. The objective of this study was to further examine the real-world rate of CNS-related EFV discontinuation in antiretroviral therapy naïve HIV-1 patients. This retrospective cohort study used a nationally representative electronic medical records database to identify HIV-1 patients ≥12 years old, treated with a 1st-line EFV-based regimen (single or combination antiretroviral tablet) from 1 January 2009 to 30 June 2013. Patients without prior record of EFV use during 6-month baseline (i.e., antiretroviral therapy naïve) were followed 12 months post-medication initiation. CNS-related EFV discontinuation was defined as evidence of a switch to a replacement antiretroviral coupled with record of a CNS symptom within 30 days prior, absent lab evidence of virologic failure. We identified 1742 1st-line EFV patients. Mean age was 48 years, 22.7% were female, and 8.1% had a prior report of CNS symptoms. The first year, overall discontinuation rate among new users of EFV was 16.2%. Ten percent of patients (n = 174) reported a CNS symptom and 1.1% (n = 19) discontinued EFV due to CNS symptoms: insomnia (n = 12), headache (n = 5), impaired concentration (n = 1), and somnolence (n = 1). The frequency of CNS symptoms was similar for patients who discontinued EFV compared to those who did not (10.3 vs. 9.9%; P = .86). Our study found that EFV discontinuation due to CNS symptoms was low, consistent with prior reports.

  5. Display methods of electronic patient record screens: patient privacy concerns.

    Science.gov (United States)

    Niimi, Yukari; Ota, Katsumasa

    2013-01-01

    To provide adequate care, medical professionals have to collect not only medical information but also information that may be related to private aspects of the patient's life. With patients' increasing awareness of information privacy, healthcare providers have to pay attention to the patients' right of privacy. This study aimed to clarify the requirements of the display method of electronic patient record (EPR) screens in consideration of both patients' information privacy concerns and health professionals' information needs. For this purpose, semi-structured group interviews were conducted of 78 medical professionals. They pointed out that partial concealment of information to meet patients' requests for privacy could result in challenges in (1) safety in healthcare, (2) information sharing, (3) collaboration, (4) hospital management, and (5) communication. They believed that EPRs should (1) meet the requirements of the therapeutic process, (2) have restricted access, (3) provide convenient access to necessary information, and (4) facilitate interprofessional collaboration. This study provides direction for the development of display methods that balance the sharing of vital information and protection of patient privacy.

  6. [Nutritional status recording in hospitalized patient notes].

    Science.gov (United States)

    Matos, L; Teixeira, M A; Henriques, A; Tavares, M M; Alvares, L; Antunes, A; Amaral, Teresa F

    2007-01-01

    The prevalence of disease-related malnutrition (DRM) is described to be of 30-60% on admission to hospital, and of 10% in the community. It has been associated with worse clinical outcomes, namely higher morbidity and mortality as well as higher frequency of health care and its associated costs. The lack of screening and monitoring of nutritional status have been said to be risk factors for the increased prevalence of DRM during hospital stay. The aims of this study were to evaluate the importance given by health care professionals to certain aspects related with nutritional status (weight, food intake) of hospital patients and to see if there were any differences between the under and non undernourished ones. A systematic sample of patients from six hospitals was collected. Pregnancy, paediatric age and critical illness were exclusion criteria as well as incapacity to fulfil nutritional risk screening protocol and length-of-stay less than 24h. Socio-demographic, anthropometric data and clinical notes (e.g. weight, food/nutrient intake) from medical records were collected and Nutritional Risk Screening 2002 protocol was applied. A total of 1152 patients were included in this study. The prevalence of nutritional risk varied between 28.5% and 47.3% while undernutrition classified by anthropometrical parameters was considerably lower (6.3% to 14.9%). Two thirds of the patients had their food intake monitored and registered in medical records but only one third were weighted. Undernourished patients had their food intake more frequently monitored but their weight was less frequently measured, than the well-nourished ones. DRM prevalence amongst hospital patients on admission is significantly high. Clinical notes regarding nutritional status is rather infrequent on medical records. This study showed that urges the need to empower health care providers of the importance of the screening and monitoring of weight and food intake, on admission and during hospital stay.

  7. Making medical records professional(s).

    Science.gov (United States)

    Mason, A

    1987-07-01

    In 1986 a joint medical records project group was set up by the Institute of Health Services Management, the Association of Health Care Information and Medical Records Officers and the NHS Training Authority, with Mr Vic Peel as chairman. The group was supported by Arthur Andersen & Co, management consultants. The following is a shortened and edited version of an interim report drafted for the group by Dr Alastair Mason. It is intended for discussion and does not yet represent the definitive views of the sponsoring bodies.

  8. Improving Care for Patients With or at Risk for Chronic Kidney Disease Using Electronic Medical Record Interventions: A Pragmatic Cluster-Randomized Trial Protocol

    Science.gov (United States)

    Nash, Danielle M.; Ivers, Noah M.; Young, Jacqueline; Jaakkimainen, R. Liisa; Garg, Amit X.; Tu, Karen

    2017-01-01

    Background: Many patients with or at risk for chronic kidney disease (CKD) in the primary care setting are not receiving recommended care. Objective: The objective of this study is to determine whether a multifaceted, low-cost intervention compared with usual care improves the care of patients with or at risk for CKD in the primary care setting. Design: A pragmatic cluster-randomized trial, with an embedded qualitative process evaluation, will be conducted. Setting: The study population comes from the Electronic Medical Record Administrative data Linked Database®, which includes clinical data for more than 140 000 rostered adults cared for by 194 family physicians in 34 clinics across Ontario, Canada. The 34 primary care clinics will be randomized to the intervention or control group. Intervention: The intervention group will receive resources from the “CKD toolkit” to help improve care including practice audit and feedback, printed educational materials for physicians and patients, electronic decision support and reminders, and implementation support. Measurements: Patients with or at risk for CKD within participating clinics will be identified using laboratory data in the electronic medical records. Outcomes will be assessed after dissemination of the CKD tools and after 2 rounds of feedback on performance on quality indicators have been sent to the physicians using information from the electronic medical records. The primary outcome is the proportion of patients aged 50 to 80 years with nondialysis-dependent CKD who are on a statin. Secondary outcomes include process of care measures such as screening tests, CKD recognition, monitoring tests, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescriptions, blood pressure targets met, and nephrologist referral. Hierarchical analytic modeling will be performed to account for clustering. Semistructured interviews will be conducted with a random purposeful sample of physicians in the

  9. Design and implementation of an affordable, public sector electronic medical record in rural Nepal.

    Science.gov (United States)

    Raut, Anant; Yarbrough, Chase; Singh, Vivek; Gauchan, Bikash; Citrin, David; Verma, Varun; Hawley, Jessica; Schwarz, Dan; Harsha Bangura, Alex; Shrestha, Biplav; Schwarz, Ryan; Adhikari, Mukesh; Maru, Duncan

    2017-06-23

    Globally, electronic medical records are central to the infrastructure of modern healthcare systems. Yet the vast majority of electronic medical records have been designed for resource-rich environments and are not feasible in settings of poverty. Here we describe the design and implementation of an electronic medical record at a public sector district hospital in rural Nepal, and its subsequent expansion to an additional public sector facility.DevelopmentThe electronic medical record was designed to solve for the following elements of public sector healthcare delivery: 1) integration of the systems across inpatient, surgical, outpatient, emergency, laboratory, radiology, and pharmacy sites of care; 2) effective data extraction for impact evaluation and government regulation; 3) optimization for longitudinal care provision and patient tracking; and 4) effectiveness for quality improvement initiatives. For these purposes, we adapted Bahmni, a product built with open-source components for patient tracking, clinical protocols, pharmacy, laboratory, imaging, financial management, and supply logistics. In close partnership with government officials, we deployed the system in February of 2015, added on additional functionality, and iteratively improved the system over the following year. This experience enabled us then to deploy the system at an additional district-level hospital in a different part of the country in under four weeks. We discuss the implementation challenges and the strategies we pursued to build an electronic medical record for the public sector in rural Nepal.DiscussionOver the course of 18 months, we were able to develop, deploy and iterate upon the electronic medical record, and then deploy the refined product at an additional facility within only four weeks. Our experience suggests the feasibility of an integrated electronic medical record for public sector care delivery even in settings of rural poverty.

  10. Learning a Health Knowledge Graph from Electronic Medical Records.

    Science.gov (United States)

    Rotmensch, Maya; Halpern, Yoni; Tlimat, Abdulhakim; Horng, Steven; Sontag, David

    2017-07-20

    Demand for clinical decision support systems in medicine and self-diagnostic symptom checkers has substantially increased in recent years. Existing platforms rely on knowledge bases manually compiled through a labor-intensive process or automatically derived using simple pairwise statistics. This study explored an automated process to learn high quality knowledge bases linking diseases and symptoms directly from electronic medical records. Medical concepts were extracted from 273,174 de-identified patient records and maximum likelihood estimation of three probabilistic models was used to automatically construct knowledge graphs: logistic regression, naive Bayes classifier and a Bayesian network using noisy OR gates. A graph of disease-symptom relationships was elicited from the learned parameters and the constructed knowledge graphs were evaluated and validated, with permission, against Google's manually-constructed knowledge graph and against expert physician opinions. Our study shows that direct and automated construction of high quality health knowledge graphs from medical records using rudimentary concept extraction is feasible. The noisy OR model produces a high quality knowledge graph reaching precision of 0.85 for a recall of 0.6 in the clinical evaluation. Noisy OR significantly outperforms all tested models across evaluation frameworks (p < 0.01).

  11. Security in the Dutch electronic patient record system

    NARCIS (Netherlands)

    van 't Noordende, G.

    2010-01-01

    In this article, we analyze the security architecture of the Dutch Electronic Patient Dossier (EPD) system. Intended as a mandatory infrastructure for exchanging medical records of most if not all patients in the Netherlands among authorized parties (particularly, physicians), the EPD has to address

  12. A cloud-based framework for large-scale traditional Chinese medical record retrieval.

    Science.gov (United States)

    Liu, Lijun; Liu, Li; Fu, Xiaodong; Huang, Qingsong; Zhang, Xianwen; Zhang, Yin

    2018-01-01

    Electronic medical records are increasingly common in medical practice. The secondary use of medical records has become increasingly important. It relies on the ability to retrieve the complete information about desired patient populations. How to effectively and accurately retrieve relevant medical records from large- scale medical big data is becoming a big challenge. Therefore, we propose an efficient and robust framework based on cloud for large-scale Traditional Chinese Medical Records (TCMRs) retrieval. We propose a parallel index building method and build a distributed search cluster, the former is used to improve the performance of index building, and the latter is used to provide high concurrent online TCMRs retrieval. Then, a real-time multi-indexing model is proposed to ensure the latest relevant TCMRs are indexed and retrieved in real-time, and a semantics-based query expansion method and a multi- factor ranking model are proposed to improve retrieval quality. Third, we implement a template-based visualization method for displaying medical reports. The proposed parallel indexing method and distributed search cluster can improve the performance of index building and provide high concurrent online TCMRs retrieval. The multi-indexing model can ensure the latest relevant TCMRs are indexed and retrieved in real-time. The semantics expansion method and the multi-factor ranking model can enhance retrieval quality. The template-based visualization method can enhance the availability and universality, where the medical reports are displayed via friendly web interface. In conclusion, compared with the current medical record retrieval systems, our system provides some advantages that are useful in improving the secondary use of large-scale traditional Chinese medical records in cloud environment. The proposed system is more easily integrated with existing clinical systems and be used in various scenarios. Copyright © 2017. Published by Elsevier Inc.

  13. From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age.

    Science.gov (United States)

    Gillum, Richard F

    2013-10-01

    A major transition is underway in documentation of patient-related data in clinical settings with rapidly accelerating adoption of the electronic health record and electronic medical record. This article examines the history of the development of medical records in the West in order to suggest lessons applicable to the current transition. The first documented major transition in the evolution of the clinical medical record occurred in antiquity, with the development of written case history reports for didactic purposes. Benefiting from Classical and Hellenistic models earlier than physicians in the West, medieval Islamic physicians continued the development of case histories for didactic use. A forerunner of modern medical records first appeared in Paris and Berlin by the early 19th century. Development of the clinical record in America was pioneered in the 19th century in major teaching hospitals. However, a clinical medical record useful for direct patient care in hospital and ambulatory settings was not developed until the 20th century. Several lessons are drawn from the 4000-year history of the medical record that may help physicians improve patient care in the digital age. Copyright © 2013 Elsevier Inc. All rights reserved.

  14. Building a national electronic medical record exchange system - experiences in Taiwan.

    Science.gov (United States)

    Li, Yu-Chuan Jack; Yen, Ju-Chuan; Chiu, Wen-Ta; Jian, Wen-Shan; Syed-Abdul, Shabbir; Hsu, Min-Huei

    2015-08-01

    There are currently 501 hospitals and about 20,000 clinics in Taiwan. The National Health Insurance (NHI) system, which is operated by the NHI Administration, uses a single-payer system and covers 99.9% of the nation's total population of 23,000,000. Taiwan's NHI provides people with a high degree of freedom in choosing their medical care options. However, there is the potential concern that the available medical resources will be overused. The number of doctor consultations per person per year is about 15. Duplication of laboratory tests and prescriptions are not rare either. Building an electronic medical record exchange system is a good method of solving these problems and of improving continuity in health care. In November 2009, Taiwan's Executive Yuan passed the 'Plan for accelerating the implementation of electronic medical record systems in medical institutions' (2010-2012; a 3-year plan). According to this plan, a patient can, at any hospital in Taiwan, by using his/her health insurance IC card and physician's medical professional IC card, upon signing a written agreement, retrieve all important medical records for the past 6 months from other participating hospitals. The focus of this plan is to establish the National Electronic Medical Record Exchange Centre (EEC). A hospital's information system will be connected to the EEC through an electronic medical record (EMR) gateway. The hospital will convert the medical records for the past 6 months in its EMR system into standardized files and save them on the EMR gateway. The most important functions of the EEC are to generate an index of all the XML files on the EMR gateways of all hospitals, and to provide search and retrieval services for hospitals and clinics. The EEC provides four standard inter-institution EMR retrieval services covering medical imaging reports, laboratory test reports, discharge summaries, and outpatient records. In this system, we adopted the Health Level 7 (HL7) Clinical Document

  15. Provider interaction with the electronic health record: the effects on patient-centered communication in medical encounters.

    Science.gov (United States)

    Street, Richard L; Liu, Lin; Farber, Neil J; Chen, Yunan; Calvitti, Alan; Zuest, Danielle; Gabuzda, Mark T; Bell, Kristin; Gray, Barbara; Rick, Steven; Ashfaq, Shazia; Agha, Zia

    2014-09-01

    The computer with the electronic health record (EHR) is an additional 'interactant' in the medical consultation, as clinicians must simultaneously or in alternation engage patient and computer to provide medical care. Few studies have examined how clinicians' EHR workflow (e.g., gaze, keyboard activity, and silence) influences the quality of their communication, the patient's involvement in the encounter, and conversational control of the visit. Twenty-three primary care providers (PCPs) from USA Veterans Administration (VA) primary care clinics participated in the study. Up to 6 patients per PCP were recruited. The proportion of time PCPs spent gazing at the computer was captured in real time via video-recording. Mouse click/scrolling activity was captured through Morae, a usability software that logs mouse clicks and scrolling activity. Conversational silence was coded as the proportion of time in the visit when PCP and patient were not talking. After the visit, patients completed patient satisfaction measures. Trained coders independently viewed videos of the interactions and rated the degree to which PCPs were patient-centered (informative, supportive, partnering) and patients were involved in the consultation. Conversational control was measured as the proportion of time the PCP held the floor compared to the patient. The final sample included 125 consultations. PCPs who spent more time in the consultation gazing at the computer and whose visits had more conversational silence were rated lower in patient-centeredness. PCPs controlled more of the talk time in the visits that also had longer periods of mutual silence. PCPs were rated as having less effective communication when they spent more time looking at the computer and when there was more periods of silence in the consultation. Because PCPs increasingly are using the EHR in their consultations, more research is needed to determine effective ways that they can verbally engage patients while simultaneously

  16. A Cloud Computing Based Patient Centric Medical Information System

    Science.gov (United States)

    Agarwal, Ankur; Henehan, Nathan; Somashekarappa, Vivek; Pandya, A. S.; Kalva, Hari; Furht, Borko

    This chapter discusses an emerging concept of a cloud computing based Patient Centric Medical Information System framework that will allow various authorized users to securely access patient records from various Care Delivery Organizations (CDOs) such as hospitals, urgent care centers, doctors, laboratories, imaging centers among others, from any location. Such a system must seamlessly integrate all patient records including images such as CT-SCANS and MRI'S which can easily be accessed from any location and reviewed by any authorized user. In such a scenario the storage and transmission of medical records will have be conducted in a totally secure and safe environment with a very high standard of data integrity, protecting patient privacy and complying with all Health Insurance Portability and Accountability Act (HIPAA) regulations.

  17. 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

  18. CLAIM (CLinical Accounting InforMation)--an XML-based data exchange standard for connecting electronic medical record systems to patient accounting systems.

    Science.gov (United States)

    Guo, Jinqiu; Takada, Akira; Tanaka, Koji; Sato, Junzo; Suzuki, Muneou; Takahashi, Kiwamu; Daimon, Hiroyuki; Suzuki, Toshiaki; Nakashima, Yusei; Araki, Kenji; Yoshihara, Hiroyuki

    2005-08-01

    With the evolving and diverse electronic medical record (EMR) systems, there appears to be an ever greater need to link EMR systems and patient accounting systems with a standardized data exchange format. To this end, the CLinical Accounting InforMation (CLAIM) data exchange standard was developed. CLAIM is subordinate to the Medical Markup Language (MML) standard, which allows the exchange of medical data among different medical institutions. CLAIM uses eXtensible Markup Language (XML) as a meta-language. The current version, 2.1, inherited the basic structure of MML 2.x and contains two modules including information related to registration, appointment, procedure and charging. CLAIM 2.1 was implemented successfully in Japan in 2001. Consequently, it was confirmed that CLAIM could be used as an effective data exchange format between EMR systems and patient accounting systems.

  19. The completeness of electronic medical record data for patients with Type 2 Diabetes in primary care and its implications for computer modelling of predicted clinical outcomes.

    Science.gov (United States)

    Staff, Michael; Roberts, Christopher; March, Lyn

    2016-10-01

    To describe the completeness of routinely collected primary care data that could be used by computer models to predict clinical outcomes among patients with Type 2 Diabetes (T2D). Data on blood pressure, weight, total cholesterol, HDL-cholesterol and glycated haemoglobin levels for regular patients were electronically extracted from the medical record software of 12 primary care practices in Australia for the period 2000-2012. The data was analysed for temporal trends and for associations between patient characteristics and completeness. General practitioners were surveyed to identify barriers to recording data and strategies to improve its completeness. Over the study period data completeness improved up to around 80% complete although the recording of weight remained poorer at 55%. T2D patients with Ischaemic Heart Disease were more likely to have their blood pressure recorded (OR 1.6, p=0.02). Practitioners reported not experiencing any major barriers to using their computer medical record system but did agree with some suggested strategies to improve record completeness. The completeness of routinely collected data suitable for input into computerised predictive models is improving although other dimensions of data quality need to be addressed. Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

  20. 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

    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...

  1. 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

  2. Patient safety and technology-driven medication

    DEFF Research Database (Denmark)

    Orbæk, Janne; Gaard, Mette; Keinicke Fabricius, Pia

    2015-01-01

    ways of educating nursing students in today's medication administration. AIM: To explore nursing students' experiences and competences with the technology-driven medication administration process. METHODS: 16 pre-graduate nursing students were included in two focus group interviews which were recorded...... for the technology-driven medication process, nursing students face difficulties in identifying and adopting best practices. The impact of using technology on the frequency, type and severity of medication errors; the technologies implications on nursing professionalism and the nurses ability to secure patient...

  3. 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

  4. 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.

  5. Reorganizing Care With the Implementation of Electronic Medical Records: A Time-Motion Study in the PICU.

    Science.gov (United States)

    Roumeliotis, Nadia; Parisien, Geneviève; Charette, Sylvie; Arpin, Elizabeth; Brunet, Fabrice; Jouvet, Philippe

    2018-04-01

    To assess caregivers' patient care time before and after the implementation of a reorganization of care plan with electronic medical records. A prospective, observational, time-motion study. A level 3 PICU. Nurses and orderlies caring for intubated patients during an 8-hour work shift before (2008-2009) and after (2016) implementation of reorganization of care in 2013. The reorganization plan included improved telecommunication for healthcare workers, increased tasks delegated to orderlies, and an ICU-specific electronic medical record (Intellispace Critical Care and Anesthesia information system, Philips Healthcare). Time spent completing various work tasks was recorded by direct observation, and proportion of time in tasks was compared for each study period. A total of 153.7 hours was observed from 22 nurses and 14 orderlies. There was no significant difference in the proportion of nursing patient care time before (68.8% [interquartile range, 48-72%]) and after (55% [interquartile range, 51-57%]) (p = 0.11) the reorganization with electronic medical record. Direct patient care task time for nurses was increased from 27.0% (interquartile range, 30-37%) before to 34.7% (interquartile range, 33-75%) (p = 0.336) after, and indirect patient care tasks decreased from 33.6% (interquartile range, 23-41%) to 18.6% (interquartile range, 16-22%) (p = 0.036). Documentation time significantly increased from 14.5% (interquartile range, 12-22%) to 26.2% (interquartile range, 23-28%) (p = 0.032). Nursing productivity ratio improved from 28.3 to 26.0. A survey revealed that nursing staff was satisfied with the electronic medical record, although there was a concern for the maintenance of oral communication in the unit. The reorganization of care with the implementation of an ICU-specific electronic medical record in the PICU did not change total patient care provided but improved nursing productivity, resulting in improved efficiency. Documentation time was significantly

  6. Impact of Electronic Medical Record Use on the Patient-Doctor Relationship and Communication: A Systematic Review.

    Science.gov (United States)

    Alkureishi, Maria Alcocer; Lee, Wei Wei; Lyons, Maureen; Press, Valerie G; Imam, Sara; Nkansah-Amankra, Akua; Werner, Deb; Arora, Vineet M

    2016-05-01

    While Electronic Medical Record (EMR) use has increased dramatically, the EMR's impact on the patient-doctor relationship remains unclear. This systematic literature review sought to understand the impact of EMR use on patient-doctor relationships and communication. Parallel searches in Ovid MEDLINE, PubMed, Scopus, PsycINFO, Cochrane Library, reference review of prior systematic reviews, meeting abstract reviews, and expert reviews from August 2013 to March 2015 were conducted. Medical Subject Heading terms related to EMR use were combined with keyword terms identifying face-to-face patient-doctor communication. English language observational or interventional studies (1995-2015) were included. Studies examining physician attitudes only were excluded. Structured data extraction compared study population, design, data collection method, and outcomes. Fifty-three of 7445 studies reviewed met inclusion criteria. Included studies used behavioral analysis (28) to objectively measure communication behaviors using video or direct observation and pre-post or cross-sectional surveys to examine patient perceptions (25). Objective studies reported EMR communication behaviors that were both potentially negative (i.e., interrupted speech, low rates of screen sharing) and positive (i.e., facilitating questions). Studies examining overall patient perceptions of satisfaction, communication or the patient-doctor relationship (n = 22) reported no change with EMR use (16); a positive impact (5) or showed mixed results (1). Study quality was not assessable. Small sample sizes limited generalizability. Publication bias may limit findings. Despite objective evidence that EMR use may negatively impact patient-doctor communication, studies examining patient perceptions found no change in patient satisfaction or patient-doctor communication. Therefore, our findings should encourage providers to adopt the EMR as a communication tool. Future research is needed to better understand how

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

    Science.gov (United States)

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

    2006-01-01

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

  8. Meeting the health information needs of prostate cancer patients using personal health records.

    Science.gov (United States)

    Pai, H H; Lau, F; Barnett, J; Jones, S

    2013-12-01

    There is interest in the use of health information technology in the form of personal health record (phr) systems to support patient needs for health information, care, and decision-making, particularly for patients with distressing, chronic diseases such as prostate cancer (pca). We sought feedback from pca patients who used a phr. For 6 months, 22 pca patients in various phases of care at the BC Cancer Agency (bcca) were given access to a secure Web-based phr called provider, which they could use to view their medical records and use a set of support tools. Feedback was obtained using an end-of-study survey on usability, satisfaction, and concerns with provider. Site activity was recorded to assess usage patterns. Of the 17 patients who completed the study, 29% encountered some minor difficulties using provider. No security breaches were known to have occurred. The two most commonly accessed medical records were laboratory test results and transcribed doctor's notes. Of survey respondents, 94% were satisfied with the access to their medical records, 65% said that provider helped to answer their questions, 77% felt that their privacy and confidentiality were preserved, 65% felt that using provider helped them to communicate better with their physicians, 83% found new and useful information that they would not have received by talking to their health care providers, and 88% said that they would continue to use provider. Our results support the notion that phrs can provide cancer patients with timely access to their medical records and health information, and can assist in communication with health care providers, in knowledge generation, and in patient empowerment.

  9. The realization of the storage of XML and middleware-based data of electronic medical records

    International Nuclear Information System (INIS)

    Liu Shuzhen; Gu Peidi; Luo Yanlin

    2007-01-01

    In this paper, using the technology of XML and middleware to design and implement a unified electronic medical records storage archive management system and giving a common storage management model. Using XML to describe the structure of electronic medical records, transform the medical data from traditional 'business-centered' medical information into a unified 'patient-centered' XML document and using middleware technology to shield the types of the databases at different departments of the hospital and to complete the information integration of the medical data which scattered in different databases, conducive to information sharing between different hospitals. (authors)

  10. SU-F-T-234: Quality Improvements in the Electronic Medical Record of Patients Treated with High Dose-Rate Brachytherapy

    Energy Technology Data Exchange (ETDEWEB)

    Diener, T [Cleveland State University, Cleveland, OH (United States); Wilkinson, D [Cleveland Clinic Foundation, Cleveland, OH (United States)

    2016-06-15

    Purpose: To improve workflow efficiency and patient safety by assessing the quality control documentation for HDR brachytherapy within our Electronic Medical Record System (Mosaiq). Methods: A list of parameters based on NRC regulations, our quality management program (QMP), recommendations of the ACR and the American Brachytherapy Society, and HDR treatment planning risks identified in our previous FMEA study was made. Next, the parameter entries were classified according to the type of data input—manual, electronic, or both. Manual entry included the electronic Brachytherapy Treatment Record (BTR) and pre-treatment Mosaiq Assessments list. Oncentra Treatment Reports (OTR) from the Oncentra Treatment Control System constituted the electronic data. The OTR includes a Pre-treatment Report for each fraction, and a Treatment Summary Report at the completion of treatment. Each entry was then examined for appropriateness and completeness of data; adjustments and additions as necessary were then made. Results: Ten out of twenty-one recorded treatment parameters were identified to be documented within both the BTR and OTR. Of these ten redundancies, eight were changed from recorded values to a simple checklist in the BTR to avoid recording errors. The other redundancies were kept in both documents due to their value to ensuring patient safety. An edit was made to the current BTR quality assessment; this change revises the definition of a medical event in accordance with ODH Regulation 3701:1-58-101. One addition was made to the current QMP documents regarding HDR. This addition requires a physician to be present through the duration of HDR treatment in accordance with ODH Regulation 3701:1-58-59; Paragraph (F); Section (2); Subsection (a). Conclusion: Careful examination of HDR documentation that originates from different sources can help to improve the accuracy and reliability of the documents. In addition, there may be a small improvement in efficiency due to

  11. Quality of Co-Prescribing NSAID and Gastroprotective Medications for Elders in The Netherlands and Its Association with the Electronic Medical Record

    NARCIS (Netherlands)

    Opondo, Dedan; Visscher, Stefan; Eslami, Saeid; Verheij, Robert A.; Korevaar, Joke C.; Abu-Hanna, Ameen

    2015-01-01

    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

  12. Quality of co-prescribing NSAID and gastroprotective medications for elders in The Netherlands and its association with the electronic medical record.

    NARCIS (Netherlands)

    Opondo, D.; Visscher, S.; Eslami, S.; Verheij, R.A.; Korevaar, J.C.; Abu-Hanna, A.

    2015-01-01

    Objective: 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. Methods: We included patients 65 years and older who

  13. 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

  14. Company project: "Evaluation of the quality of medical records as a tool of clinical risk management"

    OpenAIRE

    Anna Santa Guzzo; Mario Tecca; Enrico Marinelli; Claudio Bontempi; Caterina Palazzo; Paolo Ursillo; Giuseppe Ferro; Anna Miani; Annunziata Salvati; Stefania Catanzaro; Massimiliano Chiarini; Domenica Vittoria Colamesta; Domenico Cacchio; Patrizia Sposato; Anna Maria Lombardi

    2017-01-01

    Introduction: The medical record was defined by the Italian Ministry of Health in 1992 as "the information tool designed to record all relevant demographic and clinical information on a patient during a single hospitalization episode". Retrospective analysis of medical records is a tool for selecting direct and indirect indicators of critical issues (organizational, management, technical and professional issues). The project’s purpose being the promotion of an evaluation and self-evaluation ...

  15. Patient perceptions of electronic medical records use and ratings of care quality

    Directory of Open Access Journals (Sweden)

    Finney Rutten LJ

    2014-03-01

    Full Text Available Lila J Finney Rutten,1 Sana N Vieux,2 Jennifer L St Sauver,1 Neeraj K Arora,2 Richard P Moser,2 Ellen Burke Beckjord,3 Bradford W Hesse2 1Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; 2Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA; 3Biobehavioral Medicine in Oncology Program, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA Purpose: Despite considerable potential for improving health care quality, adoption of new technologies, such as electronic medical records (EMRs, requires prudence, to ensure that such tools are designed, implemented, and used meaningfully to facilitate patient-centered communication and care processes, and better health outcomes. The association between patients’ perceptions of health care provider use of EMRs and health care quality ratings was assessed. Method: Data from two iterations of the Health Information National Trends Survey, fielded in 2011 and 2012, were pooled for these analyses. The data were collected via mailed questionnaire, using a nationally representative listing of home addresses as the sampling frame (n=7,390. All data were weighted to provide representative estimates of quality of care ratings and physician use of EMR, in the adult US population. Descriptive statistics, t-tests, and multivariable linear regression analyses were conducted. Results: EMR use was reported significantly more frequently by females, younger age groups, non-Hispanic whites, and those with higher education, higher incomes, health insurance, and a usual source of health care. Respondents who reported physician use of EMRs had significantly higher ratings of care quality (Beta=4.83, standard error [SE]=1.7, P<0.01, controlling for sociodemographic characteristics, usual source of health care, and health insurance status. Conclusion: Nationally representative

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

    NARCIS (Netherlands)

    Fouwels, Annemarie J.; Bredie, Sebastiaan J. H.; Wollersheim, Hub; Schippers, Gerard 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

  17. 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.C.H.; Schippers, G.M.

    2009-01-01

    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 the

  18. [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.

  19. Paper versus computer: Feasibility of an electronic medical record in general pediatrics

    NARCIS (Netherlands)

    J. Roukema (Jolt); R.K. Los (Renske); S.E. Bleeker (Sacha); A.M. van Ginneken (Astrid); J. van der Lei (Johan); H.A. Moll (Henriëtte)

    2006-01-01

    textabstractBACKGROUND. Implementation of electronic medical record systems promises significant advances in patient care, because such systems enhance readability, availability, and data quality. Structured data entry (SDE) applications can prompt for completeness, provide greater accuracy and

  20. Adaptations of Personal Health Record Platform for Medical Research on Chronic Diseases

    Directory of Open Access Journals (Sweden)

    A. Krukowski

    2015-05-01

    Full Text Available The article reports on experiences in e-Health platforms and services for supporting medical research into the causes and relationships among physiological parameters and health problems concerning different chronic diseases. The Personal Health Record (PHR is a way of standardizing electronic management of medical information between patients and their physicians, including medical bodies collaborating in providing integrated medical care services. We describe roles and aims behind electronic health records, follow with applicable legal and standardizations frameworks and relevant European activities, leading to the presentation of common commercial and open-source implementations of such systems, concluding with the indication of specific adaptations enabling a use of stored personal health data for scientific research into causes and evaluation of chronic illnesses. We describe ethical and privacy concerns that are relevant to using and exchanging electronic health information.

  1. Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record.

    Science.gov (United States)

    Hamiel, Uri; Hecht, Idan; Nemet, Achia; Pe'er, Liron; Man, Vitaly; Hilely, Assaf; Achiron, Asaf

    2018-05-01

    Abbreviations are common in the medical record. Their inappropriate use may ultimately lead to patient harm, yet little is known regarding the extent of their use and their comprehension. Our aim was to assess the extent of their use, their comprehension and physicians' attitudes towards them, using ophthalmology consults in a tertiary hospital as a model. We first mapped the frequency with which English abbreviations were used in the departments' computerised databases. We then used the most frequently used abbreviations as part of a cross-sectional survey designed to assess the attitudes of non-ophthalmologist physicians towards the abbreviations and their comprehension of them. Finally, we tested whether an online lecture would improve comprehension. 4375 records were screened, and 235 physicians responded to the survey. Only 42.5% knew at least 10% of the abbreviations, and no one knew them all. Ninety-two per cent of respondents admitted to searching online for the meanings of abbreviations, and 59.1% believe abbreviations should be prohibited in medical records. A short online lecture improved the number of respondents answering correctly at least 50% of the time from 1.2% to 42% (Pmedical records and are frequently misinterpreted. Online teaching is a valuable tool for physician education. The majority of respondents believed that misinterpreting abbreviations could negatively impact patient care, and that the use of abbreviations should be prohibited in medical records. Due to low rates of comprehension and negative attitudes towards abbreviations in medical communications, we believe their use should be discouraged. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  2. Implementation of Indigenous Electronic Medical Record System to Facilitate Care of Sickle Cell Disease Patients in Chhattisgarh.

    Science.gov (United States)

    Choubey, Mona; Mishra, Hrishikesh; Soni, Khushboo; Patra, Pradeep Kumar

    2016-02-01

    Sickle cell disease (SCD) is prevalent in central India including Chhattisgarh. Screening for SCD is being carried out by Government of Chhattisgarh. Electronic Medical Record (EMR) system was developed and implemented in two phases. Aim was to use informatics techniques and indigenously develop EMR system to improve the care of SCD patients in Chhattisgarh. EMR systems had to be developed to store and manage: i) huge data generated through state wide screening for SCD; ii) clinical data for SCD patients attending the outpatient department (OPD) of institute. 'State Wide Screening Data Interface' (SWSDI) was designed and implemented for storing and managing data generated through screening program. Further, 'Sickle Cell Patients Temporal Data Management System' (SCPTDMS) was developed and implemented for storing, managing and analysing sickle cell disease patients' data at OPD. Both systems were developed using VB.Net and MS SQL Server 2012. Till April 2015, SWSDI has data of 1294558 persons, out of which 121819 and 4087 persons are carriers and patients of sickle cell disease respectively. Similarly till June 2015, SCPTDMS has data of 3760 persons, of which 923 are sickle cell disease patients (SS) and 1355 are sickle cell carriers (AS). Both systems are proving to be useful in efficient storage, management and analysis of data for clinical and research purposes. The systems are an example of beneficial usage of medical informatics solutions for managing large data at community level.

  3. Use of electronic medical records in oncology outcomes research

    Directory of Open Access Journals (Sweden)

    Gena Kanas

    2010-02-01

    Full Text Available Gena Kanas1, Libby Morimoto1, Fionna Mowat1, Cynthia O’Malley2, Jon Fryzek3, Robert Nordyke21Exponent, Inc., Menlo Park, CA, USA; 2Amgen, Inc., Thousand Oaks, CA, USA; 3MedImmune, Gaithersburg, MD, USAAbstract: Oncology outcomes research could benefit from the use of an oncology-specific electronic medical record (EMR network. The benefits and challenges of using EMR in general health research have been investigated; however, the utility of EMR for oncology outcomes research has not been explored. Compared to current available oncology databases and registries, an oncology-specific EMR could provide comprehensive and accurate information on clinical diagnoses, personal and medical histories, planned and actual treatment regimens, and post-treatment outcomes, to address research questions from patients, policy makers, the pharmaceutical industry, and clinicians/researchers. Specific challenges related to structural (eg, interoperability, data format/entry, clinical (eg, maintenance and continuity of records, variety of coding schemes, and research-related (eg, missing data, generalizability, privacy issues must be addressed when building an oncology-specific EMR system. Researchers should engage with medical professional groups to guide development of EMR systems that would ultimately help improve the quality of cancer care through oncology outcomes research.Keywords: medical informatics, health care, policy, outcomes

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

    Science.gov (United States)

    Kulynych, Jennifer; Greely, Henry T

    2017-04-01

    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.

  5. A pharmacy-based medication reconciliation and review program in hemodialysis patients: a prospective study

    Directory of Open Access Journals (Sweden)

    Patricia NJ

    2016-09-01

    Full Text Available Background: Hemodialysis (HD patients are on multiple medications, see many prescribers and have many hospitalizations which put them at risk for medication record discrepancies and medication related problems (MRP. Being able to effectively identify and reconcile these medication issues is crucial in reducing hospitalizations, morbidities, and mortalities. The care of the hemodialysis patients can be enhanced by incorporating a pharmacist into the interprofessional team. There is little data in the literature on medication record discrepancies and MRP’s in dialysis patients. Objective: The objectives of this research were to determine the types of medication discrepancies and MRPs in dialysis patients and if recommendations for changes based on these findings were accepted by providers. Methods: Patients were asked to bring medications to the dialysis unit for review. Discrepancy and MRP recommendations were communicated to the unit staff via written progress notes. A follow-up was performed an average of 33 days later to determine if the recommendations were accepted. Results: Overall, in 93 unique patients, 376 discrepancies (3.1 per patient and 64 MRPs (0.5 per patient were identified. The most common type of discrepancy and MRP was drug omission and indication without drug, respectively. Of the total 440 interventions, 77% were ultimately accepted. Discrepancies were more likely to be accepted as compared to MRPs (85% vs. 27%, respectively. Conclusion: Medication record discrepancies and MRPs are common in dialysis patients. Recommendations related to discrepancies were more likely to be accepted by the providers as compared to MRPs. Medication records became inaccurate within 12 months. A pharmacy-based medication reconciliation and review program may have an important impact on the care of hemodialysis patients.

  6. Implementation of an Electronic Medical Records System

    Science.gov (United States)

    2008-05-07

    Hartman, MAJ Roddex Barlow , CPT Christopher Besser and Capt Michael Emerson...thank you I am truly honored to call each of you my friends. Electronic... abnormal findings are addressed. 18 Electronic Medical Record Implementation Barriers of the Electronic Medical Records System There are several...examination findings • Psychological and social assessment findings N. The system provides a flexible mechanism for retrieval of encounter

  7. Application of the STOPP/START criteria to a medical record database.

    Science.gov (United States)

    Nauta, Katinka J; Groenhof, Feikje; Schuling, Jan; Hugtenburg, Jacqueline G; van Hout, Hein P J; Haaijer-Ruskamp, Flora M; Denig, Petra

    2017-10-01

    The STOPP/START criteria are increasingly used to assess prescribing quality in elderly patients at practice level. Our aim was to test computerized algorithms for applying these criteria to a medical record database. STOPP/START criteria-based computerized algorithms were defined using Anatomical-Therapeutic-Chemical (ATC) codes for medication and International Classification of Primary Care (ICPC) codes for diagnoses. The algorithms were applied to a Dutch primary care database, including patients aged ≥65 years using ≥5 chronic drugs. We tested for associations with patient characteristics that have previously shown a relationship with the original STOPP/START criteria, using multivariate logistic regression models. Included were 1187 patients with a median age of 75 years. In total, 39 of the 62 STOPP and 18 of the 26 START criteria could be converted to a computerized algorithm. The main reasons for inapplicability were lack of information on the severity of a condition and insufficient covering of ICPC-codes. We confirmed a positive association between the occurrence of both the STOPP and the START criteria and the number of chronic drugs (adjusted OR ranging from 1.37, 95% CI 1.04-1.82 to 3.19, 95% CI 2.33-4.36) as well as the patient's age (adjusted OR for STOPP 1.30, 95% CI 1.01-1.67; for START 1.73, 95% CI 1.35-2.21), and also between female gender and the occurrence of STOPP criteria (adjusted OR 1.41, 95% CI 1.09-1.82). Sixty-five percent of the STOPP/START criteria could be applied with computerized algorithms to a medical record database with ATC-coded medication and ICPC-coded diagnoses. Copyright © 2017 John Wiley & Sons, Ltd.

  8. 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.

  9. Patient Perceptions of Electronic Medical Record Use by Faculty and Resident Physicians: A Mixed Methods Study.

    Science.gov (United States)

    Lee, Wei Wei; Alkureishi, Maria A; Ukabiala, Obioma; Venable, Laura Ruth; Ngooi, Samantha S; Staisiunas, Daina D; Wroblewski, Kristen E; Arora, Vineet M

    2016-11-01

    While concerns remain regarding Electronic Medical Records (EMR) use impeding doctor-patient communication, resident and faculty patient perspectives post-widespread EMR adoption remain largely unexplored. We aimed to describe patient perspectives of outpatient resident and faculty EMR use and identify positive and negative EMR use examples to promote optimal utilization. This was a prospective mixed-methods study. Internal medicine faculty and resident patients at the University of Chicago's primary care clinic participated in the study. In 2013, one year after EMR implementation, telephone interviews were conducted with patients using open-ended and Likert style questions to elicit positive and negative perceptions of EMR use by physicians. Interview transcripts were analyzed qualitatively to develop a coding classification. Satisfaction with physician EMR use was examined using bivariate statistics. In total, 108 interviews were completed and analyzed. Two major themes were noted: (1) Clinical Functions of EMR and (2) Communication Functions of EMR; as well as six subthemes: (1a) Clinical Care (i.e., clinical efficiency), (1b) Documentation (i.e., proper record keeping and access), (1c) Information Access, (1d) Educational Resource, (2a) Patient Engagement and (2b) Physical Focus (i.e., body positioning). Overall, 85 % (979/1154) of patient perceptions of EMR use were positive, with the majority within the "Clinical Care" subtheme (n = 218). Of negative perceptions, 66 % (115/175) related to the "Communication Functions" theme, and the majority of those related to the "Physical Focus" subtheme (n = 71). The majority of patients (90 %, 95/106) were satisfied with physician EMR use: 59 % (63/107) reported the computer had a positive effect on their relationship and only 7 % (8/108) reported the EMR made it harder to talk with their doctors. Despite concerns regarding EMRs impeding doctor-patient communication, patients reported largely positive

  10. 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.

  11. A security analysis of the Dutch electronic patient record system

    NARCIS (Netherlands)

    van 't Noordende, G.

    2010-01-01

    In this article, we analyze the security architecture of the Dutch Electronic Patient Dossier (EPD) system. Intended as a national infrastructure for exchanging medical patient records among authorized parties (particularly, physicians), the EPD has to address a number of requirements, ranging from

  12. The computerized patient record: Where do we stand?

    NARCIS (Netherlands)

    Jaspers, M. W. M.; Knaup, P.; Schmidt, D.

    2006-01-01

    OBJECTIVES: To provide an overview of trends in research, developments and implementations of the computerized patient record (CPR) of the last two years. METHODS: We surveyed the medical informatics literature, spanning the years 2004-2005, focusing on publications on CPRs. RESULTS: The main trends

  13. Principle and engineering implementation of 3D visual representation and indexing of medical diagnostic records (Conference Presentation)

    Science.gov (United States)

    Shi, Liehang; Sun, Jianyong; Yang, Yuanyuan; Ling, Tonghui; Wang, Mingqing; Zhang, Jianguo

    2017-03-01

    Purpose: Due to the generation of a large number of electronic imaging diagnostic records (IDR) year after year in a digital hospital, The IDR has become the main component of medical big data which brings huge values to healthcare services, professionals and administration. But a large volume of IDR presented in a hospital also brings new challenges to healthcare professionals and services as there may be too many IDRs for each patient so that it is difficult for a doctor to review all IDR of each patient in a limited appointed time slot. In this presentation, we presented an innovation method which uses an anatomical 3D structure object visually to represent and index historical medical status of each patient, which is called Visual Patient (VP) in this presentation, based on long term archived electronic IDR in a hospital, so that a doctor can quickly learn the historical medical status of the patient, quickly point and retrieve the IDR he or she interested in a limited appointed time slot. Method: The engineering implementation of VP was to build 3D Visual Representation and Index system called VP system (VPS) including components of natural language processing (NLP) for Chinese, Visual Index Creator (VIC), and 3D Visual Rendering Engine.There were three steps in this implementation: (1) an XML-based electronic anatomic structure of human body for each patient was created and used visually to index the all of abstract information of each IDR for each patient; (2)a number of specific designed IDR parsing processors were developed and used to extract various kinds of abstract information of IDRs retrieved from hospital information systems; (3) a 3D anatomic rendering object was introduced visually to represent and display the content of VIO for each patient. Results: The VPS was implemented in a simulated clinical environment including PACS/RIS to show VP instance to doctors. We setup two evaluation scenario in a hospital radiology department to evaluate whether

  14. A clinically useful diabetes electronic medical record: lessons from the past; pointers toward the future.

    Science.gov (United States)

    Gorman, C; Looker, J; Fisk, T; Oelke, W; Erickson, D; Smith, S; Zimmerman, B

    1996-01-01

    We have analysed the deficiencies of paper medical records in facilitating the care of patients with diabetes and have developed an electronic medical record that corrects some of them. The diabetes electronic medical record (DEMR) is designed to facilitate the work of a busy diabetes clinic. Design principles include heavy reliance on graphic displays of laboratory and clinical data, consistent color coding and aggregation of data needed to facilitate the different types of clinical encounter (initial consultation, continuing care visit, insulin adjustment visit, dietitian encounter, nurse educator encounter, obstetric patient, transplant patient, visits for problems unrelated to diabetes). Data input is by autoflow from the institutional laboratories, by desk attendants or on-line by all users. Careful attention has been paid to making data entry a point and click process wherever possible. Opportunity for free text comment is provided on every screen. On completion of the encounter a narrative text summary of the visit is generated by the computer and is annotated by the care giver. Currently there are about 7800 patients in the system. Remaining challenges include the adaptation of the system to accommodate the occasional user, development of portable laptop derivatives that remain compatible with the parent system and improvements in the screen structure and graphic display formats.

  15. Expanded HIV Testing Strategy Leveraging the Electronic Medical Record Uncovers Undiagnosed Infection Among Hospitalized Patients.

    Science.gov (United States)

    Felsen, Uriel R; Cunningham, Chinazo O; Heo, Moonseong; Futterman, Donna C; Weiss, Jeffrey M; Zingman, Barry S

    2017-05-01

    Routine HIV testing of hospitalized patients is recommended, but few strategies to expand testing in the hospital setting have been described. We assessed the impact of an electronic medical record (EMR) prompt on HIV testing for hospitalized patients. We performed a pre-post study at 3 hospitals in the Bronx, NY. We compared the proportion of admissions of patients 21-64 years old with an HIV test performed, characteristics of patients tested, and rate of new HIV diagnoses made by screening while an EMR prompt recommending HIV testing was inactive vs. active. The prompt appeared for patients with no previous HIV test or a high-risk diagnosis after their last HIV test. Among 36,610 admissions while the prompt was inactive, 9.5% had an HIV test performed. Among 18,943 admissions while the prompt was active, 21.8% had an HIV test performed. Admission while the prompt was active was associated with increased HIV testing among total admissions [adjusted odds ratio (aOR) 2.78, 95% confidence interval (CI): 2.62 to 2.96], those without a previous HIV test (aOR 4.03, 95% CI: 3.70 to 4.40), and those with a previous negative test (aOR 1.52, 95% CI: 1.37 to 1.68) (P diversification of patients tested, and an increase in diagnoses made by screening.

  16. Evaluation and comparison of medical records department of Iran university of medical sciences teaching hospitals and medical records department of Kermanshah university of medical sciences teaching hospitals according to the international standards ISO 9001-2000 in 2008

    Directory of Open Access Journals (Sweden)

    maryam ahmadi

    2010-04-01

    Conclusion: The rate of final conformity of medical records system by the criteria of the ISO 9001-2000 standards in hospitals related to Iran university of medical sciences was greater than in hospitals related to Kermanshah university of medical sciences. And total conformity rate of medical records system in Kermanshah hospitals was low. So the regulation of medical records department with ISO quality management standards can help to elevate its quality.

  17. Infant feeding practices within a large electronic medical record database.

    Science.gov (United States)

    Bartsch, Emily; Park, Alison L; Young, Jacqueline; Ray, Joel G; Tu, Karen

    2018-01-02

    The emerging adoption of the electronic medical record (EMR) in primary care enables clinicians and researchers to efficiently examine epidemiological trends in child health, including infant feeding practices. We completed a population-based retrospective cohort study of 8815 singleton infants born at term in Ontario, Canada, April 2002 to March 2013. Newborn records were linked to the Electronic Medical Record Administrative data Linked Database (EMRALD™), which uses patient-level information from participating family practice EMRs across Ontario. We assessed exclusive breastfeeding patterns using an automated electronic search algorithm, with manual review of EMRs when the latter was not possible. We examined the rate of breastfeeding at visits corresponding to 2, 4 and 6 months of age, as well as sociodemographic factors associated with exclusive breastfeeding. Of the 8815 newborns, 1044 (11.8%) lacked breastfeeding information in their EMR. Rates of exclusive breastfeeding were 39.5% at 2 months, 32.4% at 4 months and 25.1% at 6 months. At age 6 months, exclusive breastfeeding rates were highest among mothers aged ≥40 vs. database.

  18. 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

  19. Cognitive complexity of the medical record is a risk factor for major adverse events.

    Science.gov (United States)

    Roberson, David; Connell, Michael; Dillis, Shay; Gauvreau, Kimberlee; Gore, Rebecca; Heagerty, Elaina; Jenkins, Kathy; Ma, Lin; Maurer, Amy; Stephenson, Jessica; Schwartz, Margot

    2014-01-01

    Patients in tertiary care hospitals are more complex than in the past, but the implications of this are poorly understood as "patient complexity" has been difficult to quantify. We developed a tool, the Complexity Ruler, to quantify the amount of data (as bits) in the patient’s medical record. We designated the amount of data in the medical record as the cognitive complexity of the medical record (CCMR). We hypothesized that CCMR is a useful surrogate for true patient complexity and that higher CCMR correlates with risk of major adverse events. The Complexity Ruler was validated by comparing the measured CCMR with physician rankings of patient complexity on specific inpatient services. It was tested in a case-control model of all patients with major adverse events at a tertiary care pediatric hospital from 2005 to 2006. The main outcome measure was an externally reported major adverse event. We measured CCMR for 24 hours before the event, and we estimated lifetime CCMR. Above empirically derived cutoffs, 24-hour and lifetime CCMR were risk factors for major adverse events (odds ratios, 5.3 and 6.5, respectively). In a multivariate analysis, CCMR alone was essentially as predictive of risk as a model that started with 30-plus clinical factors. CCMR correlates with physician assessment of complexity and risk of adverse events. We hypothesize that increased CCMR increases the risk of physician cognitive overload. An automated version of the Complexity Ruler could allow identification of at-risk patients in real time.

  20. Medical students volunteering in hospital: a novel method of exploring and recording the patient experience

    Directory of Open Access Journals (Sweden)

    Monica Lorraina Hytiris

    2017-05-01

    Full Text Available Background: Patient experience is increasingly recognised as an important feature of healthcare quality improvement. However, many of the methods implemented for its collection have significant limitations and reliability issues. This article describes how a UK healthcare organisation worked with medical student volunteers to build capacity for the collection of patient feedback in evidence-informed ways, and summarises student reflections on this process. Aims: To improve the quantity and quality of inpatient feedback, and in doing so provide new learning opportunities for medical students. Conclusions: Patient feedback gathered by volunteers is beneficial to the service and to medical student volunteers. As the feedback gathered is ward-specific, opportunities are created for practice improvements to be identified and acted on. It is feasible for medical students to be trained effectively as volunteers in gathering patient care experiences with adequate support mechanisms in place. Implications for practice: •\tHealthcare services should consider the use of personnel independent of the care team for the collection of patient feedback •\tPatient feedback needs to be shared with practitioners in a timely manner •\tMedical schools should consider this type of volunteering as a unique opportunity for medical students to improve understanding of patients’ experiences of healthcare, and of how care can be person-centred

  1. Identification and Fibrosis Staging of Hepatitis C Patients Using the Electronic Medical Record System.

    Science.gov (United States)

    Anand, Vijay; Hyun, Christian; Khan, Qasim M; Hall, Curtis; Hessefort, Norbert; Sonnenberg, Amnon; Fimmel, Claus J

    2016-09-01

    The aim of this study was to noninvasively assess the severity of chronic hepatitis C virus (HCV) in large patient populations. It would be helpful if fibrosis scores could be calculated solely on the basis of data contained in the patients' electronic medical records (EMR). We performed a pilot study to identify all HCV-infected patients in a large health care system, and predict their fibrosis stage on the basis of demographic and laboratory data using common data from their EMR. HCV-infected patients were identified using the EMR. The liver biopsies of 191 HCV patients were graded using the Ishak and Metavir scoring systems. Demographic and laboratory data were extracted from the EMR and used to calculate the aminotransferase to platelet ratio index, Fib-4, Fibrosis Index, Forns, Göteborg University Cirrhosis Index, Lok Index, and Vira-HepC. In total, 869 HCV-infected patients were identified from a population of over 1 million. In the subgroup of patients with liver biopsies, all 7 algorithms were significantly correlated with the fibrosis stage. The degree of correlation was moderate, with correlation coefficients ranging from 0.22 to 0.60. For the detection of advanced fibrosis (Metavir 3 or 4), the areas under the receiver operating characteristic curve ranged from 0.71 to 0.84, with no significant differences between the individual scores. Sensitivities, specificities, and positive and negative predictive values were within the previously reported range. All scores tended to perform better for higher fibrosis stages. Our study demonstrates that HCV-infected patients can be identified and their fibrosis staged using commonly available EMR-based algorithms.

  2. 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…

  3. An efficacy trial of an electronic health record-based strategy to inform patients on safe medication use: The role of written and spoken communication.

    Science.gov (United States)

    Curtis, Laura M; Mullen, Rebecca J; Russell, Allison; Fata, Aimee; Bailey, Stacy C; Makoul, Gregory; Wolf, Michael S

    2016-09-01

    We tested the feasibility and efficacy of an electronic health record (EHR) strategy that automated the delivery of print medication information at the time of prescribing. Patients (N=141) receiving a new prescription at one internal medicine clinic were recruited into a 2-arm physician-randomized study. We leveraged an EHR platform to automatically deliver 1-page educational 'MedSheets' to patients after medical encounters. We also assessed if physicians counseled patients via patient self-report immediately following visits. Patients' understanding was objectively measured via phone interview. 122 patients completed the trial. Most intervention patients (70%) reported receiving MedSheets. Patients reported physicians frequently counseled on indication and directions for use, but less often for risks. In multivariable analysis, written information (OR 2.78, 95% CI 1.10-7.04) and physician counseling (OR 2.95, 95% CI 1.26-6.91) were independently associated with patient understanding of risk information. Receiving both was most beneficial; 87% of those receiving counseling and MedSheets correctly recalled medication risks compared to 40% receiving neither. An EHR can be a reliable means to deliver tangible, print medication education to patients, but cannot replace the salience of physician-patient communication. Offering both written and spoken modalities produced a synergistic effect for informing patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  4. How to integrate the electronic health record and patient-centered communication into the medical visit: a skills-based approach.

    Science.gov (United States)

    Duke, Pamela; Frankel, Richard M; Reis, Shmuel

    2013-01-01

    Implementation of the electronic health record (EHR) has changed the dynamics of doctor-patient communication. Physicians train to use EHRs from a technical standpoint, giving only minimal attention to integrating the human dimensions of the doctor-patient relationship into the computer-accompanied medical visit. This article reviews the literature and proposes a model to help clinicians, residents, and students improve physician-patient communication while using the EHR. We conducted a literature search on use of communication skills when interfacing with the EHR. We observed an instructional gap and developed a model using evidence-based communication skills. This model integrates patient-centered interview skills and aims to empower physicians to remain patient centered while effectively using EHRs. It may also serve as a template for future educational and practice interventions for use of the EHR in the examination room.

  5. Electronic medical records in dermatology: Practical implications

    Directory of Open Access Journals (Sweden)

    Kaliyadan Feroze

    2009-01-01

    Full Text Available Background: Electronic medical records (EMRs can be of great use in dermatological data recording. Unfortunately, not many studies have been carried out in this specific area. Aims: We attempt to evaluate the use of an EMR system in dermatology, comparing it with a conventional paper-based system. Methods: Two hundred patient records of patients attending the dermatology outpatient department were studied over a 3-month period. Half the reports were entered in the conventional paper-based format while the other half was entered in an EMR system. The time taken for each consultation was recorded and the same was carried out for the first subsequent follow-up visit. Results: The average time taken for the completion of the EMR-based consultation for new cases was 19.15 min (range, 10-30 min; standard deviation, 6.47. The paper-based consultation had an average time of 15.70 min (range, 5-25 min; standard deviation, 6.78. The P-value (T-test was used was 0.002, which was significant. The average time taken for consultations and entering progress notes in the follow-up cases was slightly less than 10 min (9.7 for EMR while it was slightly more than 10 min (10.3 for the paper format. The difference was not statistically significant. The doctors involved also mentioned what they felt were the advantages and disadvantages of the system along with suggestions for improvement. Conclusion: The use of an EMR system in dermatology (or for that matter in any specialty may overawe most users at the beginning, but once a comfort level is established, EMR is likely to outscore conventional paper recording systems. More time-motion-case studies are required to ascertain the optimal usage of EMR systems.

  6. Request for medical records or medical records in Brazil (Justice, Public Prosecution and Police x Medical Confidentiality

    Directory of Open Access Journals (Sweden)

    Roberta Fernandes Remédio Marques

    2016-12-01

    Full Text Available The request medical records for the instruction of criminal investigations, administrative and judicial proceedings is a reality in Brazil and arouses many questions. This article aims, in the light of the legislation and case law, bring some clarification on the subject, with no claim to exhaust it.

  7. 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.

  8. A Digital Language Divide? The Relationship between Internet Medication Refills and Medication Adherence among Limited English Proficient (LEP) Patients.

    Science.gov (United States)

    Casillas, Alejandra; Moreno, Gerardo; Grotts, Jonathan; Tseng, Chi-Hong; Morales, Leo S

    2018-03-29

    Use of an Internet portal to refill medicines positively affects medication adherence among English-speakers. No prior studies, however, have specifically examined the relationship between Internet refills and medication adherence among patients who are limited English proficient (LEP). (1) Examine the relationship between Internet medication refill system use and medication adherence among linguistically diverse patients with chronic conditions and (2) compare this relationship between LEP and English-proficient (EP) patients. We analyzed 2013-2014 cross-sectional data from 509 surveyed adults in the Group Health Cooperative. Surveys were merged with plan enrollment, claims data, and electronic medical records. Medication adherence was calculated by the "Continuous Measure of Medication Gaps" (CMG) method. For Internet refill system use, patients were asked, "Have you used the health systems Internet site to refill any medications in the last 12 months?" LEP status was captured in the electronic medical record by a non-English primary language and a claims record of interpreter use in at least one clinical encounter between 2005 and 2012. We used multivariate linear regression models to examine Internet refill system use and medication adherence and compared the association between LEP and EP patients. Three hundred eighty-four patients (75%) had a calculable CMG: 134 EP and 250 LEP in the adherence analyses. In unadjusted analyses, LEP patients had lower use of the Internet refill system (p < .001) and lower adherence versus the EP group (p < .001). In multivariate analyses, LEP status (β = - 0.022, p = .047) was negatively associated with adherence, while use of the Internet refill system (β = 0.030, p = .002) was positively associated. In stratified models, use of Internet refills was positively associated with adherence, even when examining LEP (β = 0.029, p = .003) and EP patients (β = 0.027, p = .049) separately

  9. Solving the interoperability challenge of a distributed complex patient guidance system: a data integrator based on HL7's Virtual Medical Record standard.

    Science.gov (United States)

    Marcos, Carlos; González-Ferrer, Arturo; Peleg, Mor; Cavero, Carlos

    2015-05-01

    We show how the HL7 Virtual Medical Record (vMR) standard can be used to design and implement a data integrator (DI) component that collects patient information from heterogeneous sources and stores it into a personal health record, from which it can then retrieve data. Our working hypothesis is that the HL7 vMR standard in its release 1 version can properly capture the semantics needed to drive evidence-based clinical decision support systems. To achieve seamless communication between the personal health record and heterogeneous data consumers, we used a three-pronged approach. First, the choice of the HL7 vMR as a message model for all components accompanied by the use of medical vocabularies eases their semantic interoperability. Second, the DI follows a service-oriented approach to provide access to system components. Third, an XML database provides the data layer.Results The DI supports requirements of a guideline-based clinical decision support system implemented in two clinical domains and settings, ensuring reliable and secure access, high performance, and simplicity of integration, while complying with standards for the storage and processing of patient information needed for decision support and analytics. This was tested within the framework of a multinational project (www.mobiguide-project.eu) aimed at developing a ubiquitous patient guidance system (PGS). The vMR model with its extension mechanism is demonstrated to be effective for data integration and communication within a distributed PGS implemented for two clinical domains across different healthcare settings in two nations. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  10. A primer on endoscopic electronic medical records.

    Science.gov (United States)

    Atreja, Ashish; Rizk, Maged; Gurland, Brooke

    2010-02-01

    Endoscopic electronic medical record systems (EEMRs) are now increasingly utilized in many endoscopy centers. Modern EEMRs not only support endoscopy report generation, but often include features such as practice management tools, image and video clip management, inventory management, e-faxes to referring physicians, and database support to measure quality and patient outcomes. There are many existing software vendors offering EEMRs, and choosing a software vendor can be time consuming and confusing. The goal of this article is inform the readers about current functionalities available in modern EEMR and provide them with a framework necessary to find an EEMR that is best fit for their practice.

  11. Use of electronic medical record-enhanced checklist and electronic dashboard to decrease CLABSIs.

    Science.gov (United States)

    Pageler, Natalie M; Longhurst, Christopher A; Wood, Matthew; Cornfield, David N; Suermondt, Jaap; Sharek, Paul J; Franzon, Deborah

    2014-03-01

    We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line-associated bloodstream infections (CLABSI). We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children's hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data. CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes. Use of an electronic medical record-enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.

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

    Directory of Open Access Journals (Sweden)

    Don O’Mahony

    2014-03-01

    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.

  13. Patterns in Patient Access and Utilization of Online Medical Records: Analysis of MyChart.

    Science.gov (United States)

    Redelmeier, Donald A; Kraus, Nicole C

    2018-02-06

    Electronic patient portals provide a new method for sharing personal medical information with individual patients. Our aim was to review utilization patterns of the largest online patient portal in Canada's largest city. We conducted a 4-year time-trend analysis of aggregated anonymous utilization data of the MyChart patient portal at Sunnybrook Health Sciences Centre in Ontario, Canada, from January 1, 2012, through December 31, 2015. Prespecified analyses examined trends related to day (weekend vs weekday), season (July vs January), year (2012 vs 2015), and an extreme adverse weather event (ice storm of December 20-26, 2013). Primary endpoints included three measures of patient portal activity: registrations, logins, and pageviews. We identified 32,325 patients who registered for a MyChart account during the study interval. Time-trend analysis showed no sign of attenuating registrations over time. Logins were frequent, averaged 734 total per day, and showed an increasing trend over time. Pageviews mirrored logins, averaged about 3029 total per day, and equated to about 5 pageviews during the average login. The most popular pageviews were clinical notes, followed by laboratory results and medical imaging reports. All measures of patient activity were lower on weekends compared to weekdays (Psecurity breach, malware attack, or software failure occurred during the study. Online patient portals can provide a popular and reliable system for distributing personal medical information to active patients and may merit consideration for hospitals. ©Donald A Redelmeier, Nicole C Kraus. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 06.02.2018.

  14. A study of general practitioners' perspectives on electronic medical records systems in NHSScotland.

    Science.gov (United States)

    Bouamrane, Matt-Mouley; Mair, Frances S

    2013-05-21

    Primary care doctors in NHSScotland have been using electronic medical records within their practices routinely for many years. The Scottish Health Executive eHealth strategy (2008-2011) has recently brought radical changes to the primary care computing landscape in Scotland: an information system (GPASS) which was provided free-of-charge by NHSScotland to a majority of GP practices has now been replaced by systems provided by two approved commercial providers. The transition to new electronic medical records had to be completed nationally across all health-boards by March 2012. We carried out 25 in-depth semi-structured interviews with primary care doctors to elucidate GPs' perspectives on their practice information systems and collect more general information on management processes in the patient surgical pathway in NHSScotland. We undertook a thematic analysis of interviewees' responses, using Normalisation Process Theory as the underpinning conceptual framework. The majority of GPs' interviewed considered that electronic medical records are an integral and essential element of their work during the consultation, playing a key role in facilitating integrated and continuity of care for patients and making clinical information more accessible. However, GPs expressed a number of reservations about various system functionalities - for example: in relation to usability, system navigation and information visualisation. Our study highlights that while electronic information systems are perceived as having important benefits, there remains substantial scope to improve GPs' interaction and overall satisfaction with these systems. Iterative user-centred improvements combined with additional training in the use of technology would promote an increased understanding, familiarity and command of the range of functionalities of electronic medical records among primary care doctors.

  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. 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.

  17. 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

  18. Distribution of Problems, Medications and Lab Results in Electronic Health Records: The Pareto Principle at Work.

    Science.gov (United States)

    Wright, Adam; Bates, David W

    2010-01-01

    BACKGROUND: Many natural phenomena demonstrate power-law distributions, where very common items predominate. Problems, medications and lab results represent some of the most important data elements in medicine, but their overall distribution has not been reported. OBJECTIVE: Our objective is to determine whether problems, medications and lab results demonstrate a power law distribution. METHODS: Retrospective review of electronic medical record data for 100,000 randomly selected patients seen at least twice in 2006 and 2007 at the Brigham and Women's Hospital in Boston and its affiliated medical practices. RESULTS: All three data types exhibited a power law distribution. The 12.5% most frequently used problems account for 80% of all patient problems, the top 11.8% of medications account for 80% of all medication orders and the top 4.5% of lab result types account for all lab results. CONCLUSION: These three data elements exhibited power law distributions with a small number of common items representing a substantial proportion of all orders and observations, which has implications for electronic health record design.

  19. 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.

  20. 76 FR 53921 - Privacy Act of 1974; Department of Homeland Security ALL-034 Emergency Care Medical Records...

    Science.gov (United States)

    2011-08-30

    ... AGENCY: Privacy Office, DHS. ACTION: Notice of Privacy Act system of records. SUMMARY: In accordance with... Security Office of Health Affairs to collect and maintain records on individuals who receive emergency care... consistent, quality medical care. To support MQM, OHA operates the electronic Patient Care Record (ePCR), an...

  1. Taking note of the perceived value and impact of medical student chart documentation on education and patient care.

    Science.gov (United States)

    Friedman, Erica; Sainte, Michelle; Fallar, Robert

    2010-09-01

    To determine the extent of restrictions to medical student documentation in patients' records and the opinions of medical education leaders about such restrictions' impact on medical student education and patient care. Education deans (n = 126) of medical schools in the United States and Canada were surveyed to determine policies regarding placement of medical student notes in the patient record, the value of medical students' documentation in the medical record, and the use of electronic medical records (EMRs) for patient notes. The instrument was a 23-item anonymous Web survey. Seventy-nine deans responded. Over 90% believed student notes belong in medical records, but only 42% had a policy regarding this. Ninety-three percent indicated that without student notes, student education would be negatively affected. Fewer (56%) indicated that patient care would be negatively affected. Most thought limiting students' notes would negatively affect several other issues: feeling a part of the team (96%), preparation for internship (95%), and students' sense of involvement (94%). Half (52%) reported that fourth-year students could place notes in paper charts at "all" affiliated hospitals, and 6% reported that fourth-year students could do so at "no" hospitals. Although students' ability to enter notes in patients' records is believed to be important for student education, only about half of all hospitals allow all students' notes in the EMR. Policies regarding placement of student notes should be implemented to ensure students' competency in note writing and their value as members of the patient care team.

  2. Integrating phenotypic data from electronic patient records with molecular level systems biology

    DEFF Research Database (Denmark)

    Brunak, Søren

    2011-01-01

    Electronic patient records remain a rather unexplored, but potentially rich data source for discovering correlations between diseases. We describe a general approach for gathering phenotypic descriptions of patients from medical records in a systematic and non-cohort dependent manner. By extracti...... Classification of Disease ontology and is therefore in principle language independent. As a use case we show how records from a Danish psychiatric hospital lead to the identification of disease correlations, which subsequently are mapped to systems biology frameworks....

  3. Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data.

    Science.gov (United States)

    Widdifield, Jessica; Bernatsky, Sasha; Thorne, J Carter; Bombardier, Claire; Jaakkimainen, R Liisa; Wing, Laura; Paterson, J Michael; Ivers, Noah; Butt, Debra; Lyddiatt, Anne; Hofstetter, Catherine; Ahluwalia, Vandana; Tu, Karen

    2016-01-01

    The Wait Time Alliance recently established wait time benchmarks for rheumatology consultations in Canada. Our aim was to quantify wait times to primary and rheumatology care for patients with rheumatic diseases. We identified patients from primary care practices in the Electronic Medical Record Administrative data Linked Database who had referrals to Ontario rheumatologists over the period 2000-2013. To assess the full care pathway, we identified dates of symptom onset, presentation in primary care and referral from electronic medical records. Dates of rheumatologist consultations were obtained by linking with physician service claims. We determined the duration of each phase of the care pathway (symptom onset to primary care encounter, primary care encounter to referral, and referral to rheumatologist consultation) and compared them with established benchmarks. Among 2430 referrals from 168 family physicians, 2015 patients (82.9%) were seen by 146 rheumatologists within 1 year of referral. Of the 2430 referrals, 2417 (99.5%) occurred between 2005 and 2013. The main reasons for referral were osteoarthritis (32.4%) and systemic inflammatory rheumatic diseases (30.6%). Wait times varied by diagnosis and geographic region. Overall, the median wait time from referral to rheumatologist consultation was 74 (interquartile range 27-101) days; it was 66 (interquartile range 18-84) days for systemic inflammatory rheumatic diseases. Wait time benchmarks were not achieved, even for the most urgent types of referral. For systemic inflammatory rheumatic diseases, most of the delays occurred before referral. Rheumatology wait times exceeded established benchmarks. Targeted efforts are needed to promote more timely access to both primary and rheumatology care. Routine linkage of electronic medical records with administrative data may help fill important gaps in knowledge about waits to primary and specialty care.

  4. Pharmacist medication reviews to improve safety monitoring in primary care patients.

    Science.gov (United States)

    Gallimore, Casey E; Sokhal, Dimmy; Zeidler Schreiter, Elizabeth; Margolis, Amanda R

    2016-06-01

    Patients prescribed psychotropic medications within primary care are at risk of suboptimal monitoring. It is unknown whether pharmacists can improve medication safety through targeted monitoring of at risk populations. Access Community Health Centers implemented a quality improvement pilot project that included pharmacists on an integrated care team to provide medication reviews for patients. Aims were to determine whether inclusion of a pharmacist performing medication reviews within a primary care behavioral health (PCBH) practice is feasible and facilitates safe medication use. Pharmacists performed medication reviews of the electronic health record for patients referred for psychiatry consultation. Reviews were performed 1-3 months following consultation and focused on medications with known suboptimal monitoring rates. Reviews were documented within the EHR and routed to the primary care provider. Primary outcome measures were change in percentage up-to-date on monitoring and AIMS assessment, and at risk of experiencing drug interaction(s) between baseline and 3 months postreview. Secondary outcome was provider opinion of medication reviews collected via electronic survey. Reviews were performed for 144 patients. Three months postreview, percentage up-to-date on recommended monitoring increased 18% (p = .0001), at risk for drug interaction decreased 20% (p improved safety monitoring of psychotropic medications. Results identify key areas for improvement that other clinics considering integration of similar pharmacy services should consider. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

  5. 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.

  6. Patients who leave the hospital against medical advice: the role of the psychiatric consultant.

    Science.gov (United States)

    Holden, P; Vogtsberger, K N; Mohl, P C; Fuller, D S

    1989-01-01

    Previous studies have identified characteristics of patients who threaten to leave non-psychiatric units against medical advice, but few have described the role of the psychiatric consultant in the patient's decision. This study compared the medical records of 31 patients who threatened to leave the hospital against medical advice (AMA) and who were seen in consultation with the records of AMA-discharged patients who were not seen by a psychiatric consultant. Most patients who received consultations remained hospitalized or were discharged in regular fashion. Those seen soon after admission were most likely to stay. Patients were more likely to remain hospitalized if the consultant's recommendations had a practical, rather than a psychological, orientation.

  7. Hybrid Patient Record – Supporting Hybrid Interaction in Clinical Wards

    DEFF Research Database (Denmark)

    Houben, Steven; Schmidt, Mathias; Frost, Mads

    2015-01-01

    Despite the widespread dissemination of the electronic health record, the paper medical record remains an important central artefact in modern clinical work. A number of new technological solutions have been proposed to mitigate some of the configuration, mobility and awareness problems that emerge...... when using this dual record setup. In this paper, we present one such technology, the HyPR device, in which a paper record is augmented with an electronic sensing platform that is designed to reduce the configuration overhead, provide awareness cues and support mobility across the patient ward. Our...

  8. Electronic health records and patient safety: co-occurrence of early EHR implementation with patient safety practices in primary care settings.

    Science.gov (United States)

    Tanner, C; Gans, D; White, J; Nath, R; Pohl, J

    2015-01-01

    The role of electronic health records (EHR) in enhancing patient safety, while substantiated in many studies, is still debated. This paper examines early EHR adopters in primary care to understand the extent to which EHR implementation is associated with the workflows, policies and practices that promote patient safety, as compared to practices with paper records. Early adoption is defined as those who were using EHR prior to implementation of the Meaningful Use program. We utilized the Physician Practice Patient Safety Assessment (PPPSA) to compare primary care practices with fully implemented EHR to those utilizing paper records. The PPPSA measures the extent of adoption of patient safety practices in the domains: medication management, handoffs and transition, personnel qualifications and competencies, practice management and culture, and patient communication. Data from 209 primary care practices responding between 2006-2010 were included in the analysis: 117 practices used paper medical records and 92 used an EHR. Results showed that, within all domains, EHR settings showed significantly higher rates of having workflows, policies and practices that promote patient safety than paper record settings. While these results were expected in the area of medication management, EHR use was also associated with adoption of patient safety practices in areas in which the researchers had no a priori expectations of association. Sociotechnical models of EHR use point to complex interactions between technology and other aspects of the environment related to human resources, workflow, policy, culture, among others. This study identifies that among primary care practices in the national PPPSA database, having an EHR was strongly empirically associated with the workflow, policy, communication and cultural practices recommended for safe patient care in ambulatory settings.

  9. Identification of Dyslipidemic Patients Attending Primary Care Clinics Using Electronic Medical Record (EMR) Data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) Database.

    Science.gov (United States)

    Aref-Eshghi, Erfan; Oake, Justin; Godwin, Marshall; Aubrey-Bassler, Kris; Duke, Pauline; Mahdavian, Masoud; Asghari, Shabnam

    2017-03-01

    The objective of this study was to define the optimal algorithm to identify patients with dyslipidemia using electronic medical records (EMRs). EMRs of patients attending primary care clinics in St. John's, Newfoundland and Labrador (NL), Canada during 2009-2010, were studied to determine the best algorithm for identification of dyslipidemia. Six algorithms containing three components, dyslipidemia ICD coding, lipid lowering medication use, and abnormal laboratory lipid levels, were tested against a gold standard, defined as the existence of any of the three criteria. Linear discriminate analysis, and bootstrapping were performed following sensitivity/specificity testing and receiver's operating curve analysis. Two validating datasets, NL records of 2011-2014, and Canada-wide records of 2010-2012, were used to replicate the results. Relative to the gold standard, combining laboratory data together with lipid lowering medication consumption yielded the highest sensitivity (99.6%), NPV (98.1%), Kappa agreement (0.98), and area under the curve (AUC, 0.998). The linear discriminant analysis for this combination resulted in an error rate of 0.15 and an Eigenvalue of 1.99, and the bootstrapping led to AUC: 0.998, 95% confidence interval: 0.997-0.999, Kappa: 0.99. This algorithm in the first validating dataset yielded a sensitivity of 97%, Negative Predictive Value (NPV) = 83%, Kappa = 0.88, and AUC = 0.98. These figures for the second validating data set were 98%, 93%, 0.95, and 0.99, respectively. Combining laboratory data with lipid lowering medication consumption within the EMR is the best algorithm for detecting dyslipidemia. These results can generate standardized information systems for dyslipidemia and other chronic disease investigations using EMRs.

  10. A retrospective analysis of medical record use in e-consultations.

    Science.gov (United States)

    Pecina, Jennifer L; North, Frederick

    2017-06-01

    Introduction Under certain circumstances, e-consultations can substitute for a face-to-face consultation. A basic requirement for a successful e-consultation is that the e-consultant has access to important medical history and exam findings along with laboratory and imaging results. Knowing just what information the specialist needs to complete an e-consultation is a major challenge. This paper examines differences between specialties in their need for past information from laboratory, imaging and clinical notes. Methods This is a retrospective study of patients who had an internal e-consultation performed at an academic medical centre. We reviewed a random sample of e-consultations that occurred in the first half of 2013 for the indication for the e-consultation and whether the e-consultant reviewed data in the medical record that was older than one year to perform the e-consultation. Results Out of 3008 total e-consultations we reviewed 360 (12%) randomly selected e-consultations from 12 specialties. Questions on management (35.8%), image results (27.2%) and laboratory results (25%) were the three most common indications for e-consultation. E-consultants reviewed medical records in existence more than one year prior to the e-consultation 146 (40.6%) of the time with e-consultants in the specialties of endocrinology, haematology and rheumatology, reviewing records older than one year more than half the time. Labs (20.3%), office notes (20%) and imaging (17.8%) were the types of medical data older than one year that were reviewed the most frequently overall. Discussion Management questions appear to be the most common reason for e-consultation. E-consultants frequently reviewed historical medical data that is older than one year at the time of the e-consultation, especially in endocrinology, haematology and rheumatology specialties. Practices engaging in e-consultations that require transfer of data may want to include longer time frames of historical information

  11. Electronic medical records in diabetes consultations: participants' gaze as an interactional resource.

    Science.gov (United States)

    Rhodes, Penny; Small, Neil; Rowley, Emma; Langdon, Mark; Ariss, Steven; Wright, John

    2008-09-01

    Two routine consultations in primary care diabetes clinics are compared using extracts from video recordings of interactions between nurses and patients. The consultations were chosen to present different styles of interaction, in which the nurse's gaze was either primarily toward the computer screen or directed more toward the patient. Using conversation analysis, the ways in which nurses shift both gaze and body orientation between the computer screen and patient to influence the style, pace, content, and structure of the consultation were investigated. By examining the effects of different levels of engagement between the electronic medical record and the embodied patient in the consultation room, we argue for the need to consider the contingent nature of the interface of technology and the person in the consultation. Policy initiatives designed to deliver what is considered best-evidenced practice are modified in the micro context of the interactions of the consultation.

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

    Directory of Open Access Journals (Sweden)

    Chen Lin

    Full Text Available 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.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.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.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.

  13. Medical records documentation of constipation preceding Parkinson disease: A case-control study.

    Science.gov (United States)

    Savica, R; Carlin, J M; Grossardt, B R; Bower, J H; Ahlskog, J E; Maraganore, D M; Bharucha, A E; Rocca, W A

    2009-11-24

    Parkinson disease (PD) may affect the autonomic nervous system and may cause constipation; however, few studies have explored constipation preceding the motor onset of PD. We investigated constipation preceding PD using a case-control study design in a population-based sample. Using the medical records-linkage system of the Rochester Epidemiology Project, we identified 196 subjects who developed PD in Olmsted County, MN, from 1976 through 1995. Each incident case was matched by age (+/-1 year) and sex to a general population control. We reviewed the complete medical records of cases and controls in the medical records-linkage system to ascertain the occurrence of constipation preceding the onset of PD (or index year). Constipation preceding PD or the index year was more common in cases than in controls (odds ratio [OR] 2.48; 95% confidence interval [CI] 1.49 to 4.11; p = 0.0005). This association remained significant after adjusting for smoking and coffee consumption (ever vs never), and after excluding constipation possibly induced by drugs. In addition, the association remained significant in analyses restricted to constipation documented 20 or more years before the onset of motor symptoms of PD. Although the association was stronger in women than in men and in patients with PD with rest tremor compared with patients with PD without rest tremor, these differences were not significant. Our findings suggest that constipation occurring as early as 20 or more years before the onset of motor symptoms is associated with an increased risk of Parkinson disease.

  14. SynopSIS: integrating physician sign-out with the electronic medical record.

    Science.gov (United States)

    Sarkar, Urmimala; Carter, Jonathan T; Omachi, Theodore A; Vidyarthi, Arpana R; Cucina, Russell; Bokser, Seth; van Eaton, Erik; Blum, Michael

    2007-09-01

    Safe delivery of care depends on effective communication among all health care providers, especially during transfers of care. The traditional medical chart does not adequately support such communication. We designed a patient-tracking tool that enhances provider communication and supports clinical decision making. To develop a problem-based patient-tracking tool, called Sign-out, Information Retrieval, and Summary (SynopSIS), in order to support patient tracking, transfers of care (ie, sign-outs), and daily rounds. Tertiary-care, university-based teaching hospital. SynopSIS compiles and organizes information from the electronic medical record to support hospital discharge and disposition decisions, daily provider decisions, and overnight or cross-coverage decisions. It reflects the provider's patient-care and daily work-flow needs. We plan to use Web-based surveys, audits of daily use, and interdisciplinary focus groups to evaluate SynopSIS's impact on communication between providers, quality of sign-out, patient continuity of care, and rounding efficiency. We expect SynopSIS to improve care by facilitating communication between care teams, standardizing sign-out, and automating daily review of clinical and laboratory trends. SynopSIS redesigns the clinical chart to better serve provider and patient needs. (c) 2007 Society of Hospital Medicine.

  15. Preparing for Electronic Medical Record Implementation: Carolina Care Communication in an Electronic Environment.

    Science.gov (United States)

    Carroll, Tracy; Tonges, Mary; Ray, Joel

    2017-11-01

    This article describes 1 organization's successful approach to mitigating the potential negative effects of a new electronic medical record on patient experience. The Carolina Care model, developed at the University of North Carolina Hospitals to actualize caring theory in practice, helped to structure and greatly facilitate this work. Seven focus areas were integrated to create the "Communication in an Electronic Environment" program with a strong emphasis on nurse-patient communication.

  16. Designing a patient-centered personal health record to promote preventive care

    Directory of Open Access Journals (Sweden)

    Krist Alex H

    2011-11-01

    Full Text Available Abstract Background Evidence-based preventive services offer profound health benefits, yet Americans receive only half of indicated care. A variety of government and specialty society policy initiatives are promoting the adoption of information technologies to engage patients in their care, such as personal health records, but current systems may not utilize the technology's full potential. Methods Using a previously described model to make information technology more patient-centered, we developed an interactive preventive health record (IPHR designed to more deeply engage patients in preventive care and health promotion. We recruited 14 primary care practices to promote the IPHR to all adult patients and sought practice and patient input in designing the IPHR to ensure its usability, salience, and generalizability. The input involved patient usability tests, practice workflow observations, learning collaboratives, and patient feedback. Use of the IPHR was measured using practice appointment and IPHR databases. Results The IPHR that emerged from this process generates tailored patient recommendations based on guidelines from the U.S. Preventive Services Task Force and other organizations. It extracts clinical data from the practices' electronic medical record and obtains health risk assessment information from patients. Clinical content is translated and explained in lay language. Recommendations review the benefits and uncertainties of services and possible actions for patients and clinicians. Embedded in recommendations are self management tools, risk calculators, decision aids, and community resources - selected to match patient's clinical circumstances. Within six months, practices had encouraged 14.4% of patients to use the IPHR (ranging from 1.5% to 28.3% across the 14 practices. Practices successfully incorporated the IPHR into workflow, using it to prepare patients for visits, augment health behavior counseling, explain test results

  17. Development of the electronic patient record system based on problem oriented system.

    Science.gov (United States)

    Uto, Yumiko; Iwaanakuchi, Takashi; Muranaga, Fuminori; Kumamoto, Ichiro

    2013-01-01

    In Japan, POS (problem oriented system) is recommended in the clinical guideline. Therefore, the records are mainly made by SOAP. We developed a system mainly with a function which enabled our staff members of all kinds of professions including doctors to enter the patients' clinical information as an identical record, regardless if they were outpatients or inpatients, and to observe the contents chronologically. This electric patient record system is called "e-kanja recording system". On this system, all staff members in the medical team can now share the same information. Moreover, the contents can be reviewed by colleagues; the quality of records has been improved as it is evaluated by the others.

  18. Symptom burden and splenomegaly in patients with myelofibrosis in the United States: a retrospective medical record review

    International Nuclear Information System (INIS)

    Mitra, Debanjali; Kaye, James A; Piecoro, Lance T; Brown, Jennifer; Reith, Kelly; Mughal, Tariq I; Sarlis, Nicholas J

    2013-01-01

    Myelofibrosis (MF) is a clonal hematopoietic malignancy characterized by constitutional and localized symptoms, progressive splenomegaly, bone marrow fibrosis, and cytopenias. Although MF is well studied, few studies exist regarding its symptomatic burden in routine clinical practice. This study aimed to characterize symptoms and other clinical features of MF among patients in the United States. We conducted a retrospective medical record review of adult patients with an MF diagnosis between 1 January 2005 and 31 March 2010, stratified by the presence of palpable splenomegaly. Eligible patients had 12 months or more of follow-up after diagnosis (or after detection of splenomegaly, if present) unless death occurred. Demographic and clinical characteristics, MF-related symptoms, and treatments were reported by treating physicians. We report on 180 MF patients: 102 with splenomegaly, 78 without. Median age was 66 years, 63% were male, and 82% had intermediate-2 or high-risk MF (International Prognostic Scoring System). Fatigue was reported by ∼85% of patients; weight loss, night sweats, and fever (any grade) were each reported by 50% or more of patients. Generalized abdominal pain, left subcostal pain, and early satiety occurred more frequently among patients with splenomegaly. Multiple symptoms were reported by 95% of patients. Common comorbidities were hypertension, diabetes, and chronic pulmonary disease. Symptoms are common in MF patients, regardless of the presence of palpable splenomegaly. Careful assessment of symptom burden is an important aspect of the clinical evaluation of patients with MF

  19. Patterns in Patient Access and Utilization of Online Medical Records: Analysis of MyChart

    Science.gov (United States)

    2018-01-01

    Background Electronic patient portals provide a new method for sharing personal medical information with individual patients. Objective Our aim was to review utilization patterns of the largest online patient portal in Canada's largest city. Methods We conducted a 4-year time-trend analysis of aggregated anonymous utilization data of the MyChart patient portal at Sunnybrook Health Sciences Centre in Ontario, Canada, from January 1, 2012, through December 31, 2015. Prespecified analyses examined trends related to day (weekend vs weekday), season (July vs January), year (2012 vs 2015), and an extreme adverse weather event (ice storm of December 20-26, 2013). Primary endpoints included three measures of patient portal activity: registrations, logins, and pageviews. Results We identified 32,325 patients who registered for a MyChart account during the study interval. Time-trend analysis showed no sign of attenuating registrations over time. Logins were frequent, averaged 734 total per day, and showed an increasing trend over time. Pageviews mirrored logins, averaged about 3029 total per day, and equated to about 5 pageviews during the average login. The most popular pageviews were clinical notes, followed by laboratory results and medical imaging reports. All measures of patient activity were lower on weekends compared to weekdays (P<.001) yet showed no significant changes related to seasons or extreme weather. No major security breach, malware attack, or software failure occurred during the study. Conclusions Online patient portals can provide a popular and reliable system for distributing personal medical information to active patients and may merit consideration for hospitals. PMID:29410386

  20. [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.

  1. 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

  2. Minimally disruptive medicine is needed for patients with multimorbidity: time to develop computerised medical record systems to meet this requirement

    Directory of Open Access Journals (Sweden)

    Peter Schattner

    2015-02-01

    Full Text Available Background Minimally disruptive medicine (MDM is proposed as a method for more appropriately managing people with multiple chronic disease. Much clinical management is currently single disease focussed, with people with multimorbidity being managed according to multiple single disease guidelines. Current initiatives to improve care include education about individual conditions and creating an environment where multiple guidelines might be simultaneously supported. The patientcentred medical home (PCMH is an example of the latter. However, educational programmes and PCMH may increase the burden on patients.Problem The cumulative workload for patients in managing the impact of multiple disease-specific guidelines is only relatively recently recognised. There is an intellectual vacuum as to how best to manage multimorbidity and how informatics might support implementing MDM. There is currently no alternative to multiple singlecondition- specific guidelines and a lack of certainty, should the treatment burden need to be reduced, as to which guideline might be ‘dropped’.Action The best information about multimorbidity is recorded in primary care computerised medical record (CMR systems and in an increasing number of integrated care organisations. CMR systems have the potential to flag individuals who might be in greatest need. However, CMR systems may also provide insights into whether there are ameliorating factors that might make it easier for them to be resilient to the burden of care. Data from such CMR systems might be used to develop the evidence base about how to better manage multimorbidity.Conclusions There is potential for these information systems to help reduce the management burden on patients and clinicians. However, substantial investment in research-driven CMR development is needed if we are to achieve this.

  3. Ethno-Cultural Considerations in Cardiac Patients' Medication Adherence.

    Science.gov (United States)

    King-Shier, K M; Singh, S; Khan, N A; LeBlanc, P; Lowe, J C; Mather, C M; Chong, E; Quan, H

    2017-10-01

    We aimed to develop an in-depth understanding about factors that influence cardiac medication adherence among South Asian, Chinese, and European White cardiac patients. Sixty-four patients were purposively sampled from an ongoing study cohort. Interviews were audio-recorded and transcribed for analyses. Physicians' culturally sensitive communication and patients' motivation to live a symptom-free and longer life enhanced adherence. European Whites were motivated to enhance personal well-being and enjoy family life. South Asians' medication adherence was influenced by the desire to fulfill the will of God and family responsibilities. The Chinese were motivated to avoid pain, illness, and death, and to obey a health care provider. The South Asians and Chinese wanted to ultimately reduce medication use. Previous positive experiences, family support, and establishing a routine also influenced medication adherence. Deterrents to adherence were essentially the reverse of the motivators/facilitators. This analysis represents an essential first step forward in developing ethno-culturally tailored interventions to optimize adherence.

  4. Electronic medical record systems are associated with appropriate placement of HIV patients on antiretroviral therapy in rural health facilities in Kenya: a retrospective pre-post study

    NARCIS (Netherlands)

    Oluoch, Tom; Katana, Abraham; Ssempijja, Victor; Kwaro, Daniel; Langat, Patrick; Kimanga, Davies; Okeyo, Nicky; Abu-Hanna, Ameen; de Keizer, Nicolette

    2014-01-01

    There is little evidence that electronic medical record (EMR) use is associated with better compliance with clinical guidelines on initiation of antiretroviral therapy (ART) among ART-eligible HIV patients. We assessed the effect of transitioning from paper-based to an EMR-based system on

  5. Prevalence of Sharing Access Credentials in Electronic Medical Records

    Science.gov (United States)

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

    2017-01-01

    Objectives 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. Methods 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. Results 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. Conclusions 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. PMID:28875052

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

    Science.gov (United States)

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

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

  7. 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.

  8. Privacy preservation and information security protection for patients' portable electronic health records.

    Science.gov (United States)

    Huang, Lu-Chou; Chu, Huei-Chung; Lien, Chung-Yueh; Hsiao, Chia-Hung; Kao, Tsair

    2009-09-01

    As patients face the possibility of copying and keeping their electronic health records (EHRs) through portable storage media, they will encounter new risks to the protection of their private information. In this study, we propose a method to preserve the privacy and security of patients' portable medical records in portable storage media to avoid any inappropriate or unintentional disclosure. Following HIPAA guidelines, the method is designed to protect, recover and verify patient's identifiers in portable EHRs. The results of this study show that our methods are effective in ensuring both information security and privacy preservation for patients through portable storage medium.

  9. Use of communication tool within electronic medical record to improve primary nonadherence.

    Science.gov (United States)

    Kerner, Daniel E; Knezevich, Emily L

    The primary objective of this study was to determine if an online reminder decreased the rate of primary nonadherence for antihypertensive medications in patients seen in 2 primary care clinics in Omaha, NE. The secondary objectives were to determine if patients receiving the intervention achieved lower blood pressure values at follow-up visits and to determine if the intervention decreased the number of days between prescribing and prescription pick-up. A report was generated in an electronic health record to identify patients prescribed a new antihypertensive medication from a physician at one of the primary care clinics. Patients that failed to pick up this new prescription from the pharmacy within 7 days were sent an electronic reminder via an online patient portal. A baseline comparator group was created with the use of retrospective chart reviews for the 6 months before prospective data collection. Primary nonadherence rate and blood pressure values at follow-up visits were compared between the prospective and baseline comparator groups. The primary nonadherence rate decreased from 65.5% to 22.2% when comparing the baseline and prospective groups, respectively. The mean days to prescription pick-up decreased from 24.5 to 12.56 in the baseline and prospective groups. The prospective group showed a larger decrease in systolic blood pressure (17.33 mm Hg vs. 0.75 mm Hg) and diastolic blood pressure (6.56 mm Hg vs. 2.25 mm Hg) compared with the baseline group. An online reminder through the electronic medical record appears to improve patient primary nonadherence, number of days between prescribing and prescription pick-up, and blood pressure measurements at follow-up visits. This research shows that an online reminder may be a valuable tool to improve patient primary adherence and health outcomes. Further research is needed with the use of a larger sample population to support any hypotheses about the effectiveness of the intervention. Copyright © 2017 American

  10. Enhanced identification of eligibility for depression research using an electronic medical record search engine.

    Science.gov (United States)

    Seyfried, Lisa; Hanauer, David A; Nease, Donald; Albeiruti, Rashad; Kavanagh, Janet; Kales, Helen C

    2009-12-01

    Electronic medical records (EMRs) have become part of daily practice for many physicians. Attempts have been made to apply electronic search engine technology to speed EMR review. This was a prospective, observational study to compare the speed and clinical accuracy of a medical record search engine vs. manual review of the EMR. Three raters reviewed 49 cases in the EMR to screen for eligibility in a depression study using the electronic medical record search engine (EMERSE). One week later raters received a scrambled set of the same patients including 9 distractor cases, and used manual EMR review to determine eligibility. For both methods, accuracy was assessed for the original 49 cases by comparison with a gold standard rater. Use of EMERSE resulted in considerable time savings; chart reviews using EMERSE were significantly faster than traditional manual review (p=0.03). The percent agreement of raters with the gold standard (e.g. concurrent validity) using either EMERSE or manual review was not significantly different. Using a search engine optimized for finding clinical information in the free-text sections of the EMR can provide significant time savings while preserving clinical accuracy. The major power of this search engine is not from a more advanced and sophisticated search algorithm, but rather from a user interface designed explicitly to help users search the entire medical record in a way that protects health information.

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

    Science.gov (United States)

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

    2015-02-01

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

  12. SU-E-T-502: Biometrically Accepted Patient Records

    International Nuclear Information System (INIS)

    Basavatia, A; Kalnicki, S; Garg, M; Lukaj, A; Hong, L; Fret, J; Yaparpalvi, R; Tome, W

    2014-01-01

    Purpose: To implement a clinically useful palm vein pattern recognition biometric system to treat the correct treatment plan to the correct patient each and every time and to check-in the patient into the department to access the correct medical record. Methods: A commercially available hand vein scanning system was paired to Aria and utilized an ADT interface from the hospital electronic health system. Integration at two points in Aria, version 11 MR2, first at the appointment tracker screen for the front desk medical record access and second at the queue screen on the 4D treatment console took place for patient daily time-out. A test patient was utilized to check accuracy of identification as well as to check that no unintended interactions take place between the 4D treatment console and the hand vein scanning system. This system has been in clinical use since December 2013. Results: Since implementation, 445 patients have been enrolled into our biometric system. 95% of patients learn the correct methodology of hand placement on the scanner in the first try. We have had two instances of patient not found because of a bad initial scan. We simply erased the scanned metric and the patient enrolled again in those cases. The accuracy of the match is 100% for each patient, we have not had one patient misidentified. We can state this because we still use patient photo and date of birth as identifiers. A QA test patient is run monthly to check the integrity of the system. Conclusion: By utilizing palm vein scans along with the date of birth and patient photo, another means of patient identification now exits. This work indicates the successful implementation of technology in the area of patient safety by closing the gap of treating the wrong plan to a patient in radiation oncology. FOJP Service Corporation covered some of the costs of the hardware and software of the palm vein pattern recognition biometric system

  13. SU-E-T-502: Biometrically Accepted Patient Records

    Energy Technology Data Exchange (ETDEWEB)

    Basavatia, A; Kalnicki, S; Garg, M; Lukaj, A; Hong, L [Montefiore Medical Center, Bronx, NY (United States); Fret, J [Montefiore Information Technology, Yonkers, NY (United States); Yaparpalvi, R [Montefiore Medical Center, Bronx, NY (United States); Montefiore Medical Center, Bronx, NY (United States); Tome, W [Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (United States)

    2014-06-01

    Purpose: To implement a clinically useful palm vein pattern recognition biometric system to treat the correct treatment plan to the correct patient each and every time and to check-in the patient into the department to access the correct medical record. Methods: A commercially available hand vein scanning system was paired to Aria and utilized an ADT interface from the hospital electronic health system. Integration at two points in Aria, version 11 MR2, first at the appointment tracker screen for the front desk medical record access and second at the queue screen on the 4D treatment console took place for patient daily time-out. A test patient was utilized to check accuracy of identification as well as to check that no unintended interactions take place between the 4D treatment console and the hand vein scanning system. This system has been in clinical use since December 2013. Results: Since implementation, 445 patients have been enrolled into our biometric system. 95% of patients learn the correct methodology of hand placement on the scanner in the first try. We have had two instances of patient not found because of a bad initial scan. We simply erased the scanned metric and the patient enrolled again in those cases. The accuracy of the match is 100% for each patient, we have not had one patient misidentified. We can state this because we still use patient photo and date of birth as identifiers. A QA test patient is run monthly to check the integrity of the system. Conclusion: By utilizing palm vein scans along with the date of birth and patient photo, another means of patient identification now exits. This work indicates the successful implementation of technology in the area of patient safety by closing the gap of treating the wrong plan to a patient in radiation oncology. FOJP Service Corporation covered some of the costs of the hardware and software of the palm vein pattern recognition biometric system.

  14. Electronic patient record and archive of records in Cardio.net system for telecardiology.

    Science.gov (United States)

    Sierdziński, Janusz; Karpiński, Grzegorz

    2003-01-01

    In modern medicine the well structured patient data set, fast access to it and reporting capability become an important question. With the dynamic development of information technology (IT) such question is solved via building electronic patient record (EPR) archives. We then obtain fast access to patient data, diagnostic and treatment protocols etc. It results in more efficient, better and cheaper treatment. The aim of the work was to design a uniform Electronic Patient Record, implemented in cardio.net system for telecardiology allowing the co-operation among regional hospitals and reference centers. It includes questionnaires for demographic data and questionnaires supporting doctor's work (initial diagnosis, final diagnosis, history and physical, ECG at the discharge, applied treatment, additional tests, drugs, daily and periodical reports). The browser is implemented in EPR archive to facilitate data retrieval. Several tools for creating EPR and EPR archive were used such as: XML, PHP, Java Script and MySQL. The separate question is the security of data on WWW server. The security is ensured via Security Socket Layer (SSL) protocols and other tools. EPR in Cardio.net system is a module enabling the co-work of many physicians and the communication among different medical centers.

  15. Transfusion-associated circulatory overload in adult, medical emergency patients with perspectives on early warning practice

    DEFF Research Database (Denmark)

    Gosmann, Fanny; Nørgaard, Astrid; Rasmussen, Maj-Britt

    2018-01-01

    of transfusion-associated dyspnoea. Vital signs and changes in dyspnoea and blood pressure were registered within the frame of the Early Warning Score, and one case was documented as being transfusion-related in the medical record. No cases were reported to the haemovigilance system. DISCUSSION: The incidence...... to the haemovigilance system. The clinical implications are discussed within the frame of the Early Warning Score. METHODS: We conducted a retrospective audit of electronic hospital medical records of patients receiving blood transfusion in a single medical emergency unit. Patients were admitted during a 6-month period...... and data on symptoms and vital signs were extracted from the records. RESULTS: Of 4,353 consecutively admitted patients, 156 patients were transfused with a total of 411 blood components. The audit identified five cases of transfusion-associated circulatory overload (incidence 3.2%) and four cases...

  16. Implementation of an Electronic Medical Records System

    National Research Council Canada - National Science Library

    Fletcher, Chadwick B

    2008-01-01

    .... Substantial benefits are realized through routine use of electronic medical records include improved quality, safety, and efficiency, along with the increased ability to conduct education and research...

  17. Continuous 24-hour ocular dimensional profile recording in medically treated normal-tension glaucoma

    Directory of Open Access Journals (Sweden)

    Lee JWY

    2015-01-01

    Full Text Available Jacky WY Lee,1,2 Lin Fu,1 Jennifer WH Shum,1 Jonathan CH Chan,3 Jimmy SM Lai1 1Department of Ophthalmology, The University of Hong Kong, Hong Kong; 2Department of Ophthalmology, Caritas Medical Centre, Hong Kong; 3Department of Ophthalmology, Queen Mary Hospital, Hong Kong Purpose: To analyze the 24-hour ocular dimensional profile in normal-tension glaucoma (NTG patients on medical treatment.Methods: Consecutive, medically treated NTG subjects were recruited from a university eye center. Subjects were on a mean of 1.7±0.7 types of antiglaucoma medications and 56.6% were on a prostaglandin analog. A contact lens-based sensor device was worn in one eye of NTG patients to record the intraocular pressure (IOP-related profile for 24 hours, recording the following: variability from mean over 24 hours, nocturnally and diurnally, as well as the number of peaks and troughs diurnally and nocturnally.Results: In 18 NTG subjects, the nocturnal variability around the mean contact lens-based sensor device signal was 48.9% less than the diurnal variability around the mean. The number of peaks was 54.7% less during the nocturnal period than during the diurnal period. The rate of increase in the ocular dimensional profile when going to sleep was significantly greater than the rate of decrease upon waking (P<0.001.Conclusion: In medically treated NTG subjects, there was more variability in the IOP-related pattern during the daytime and there were fewer peaks during sleep. Keywords: intraocular pressure, 24-hour, normal tension glaucoma

  18. 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…

  19. 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.

  20. Can audio recording of outpatient consultations improve patients recall and understanding?

    DEFF Research Database (Denmark)

    Wolderslund, Maiken

    of the dialogue between the patient and the clinician via the telephone in the consultation room. By dialing a dedicated number, patients can get access to an audio recording of their consultation by entering their social security number along with a PIN. The primary objective of this study is to determine......Introduction Information provided in an outpatient consultation concerns medication, diagnostic tests, treatment and rehabilitation, all of which are crucial knowledge with regards to patient compliance, decision making and general patient satisfaction. Despite good communication skills among...... clinicians, the communication is challenged by the fact that patients tend to forget or misunderstand parts of the information given. Thus we have designed a study which gives the patients a possibility to hear their consultation again. An Interactive Voice Response platform enables an audio recording...

  1. Salivary changes in medically compromised patients: A clinical and biochemical study

    Directory of Open Access Journals (Sweden)

    Yehoshuva R Tummuru

    2017-01-01

    Full Text Available Introduction: Medically compromised patients require special attention when dental procedures are performed on them. These individuals may require modified or slightly altered techniques. Aims and Objectives: The present study was taken up with two main objectives. The first one being examining and recording various oral manifestations in medically compromised patients, and the second objective was to collect samples of saliva from such patients and to analyze and establish any salivary changes in such medically compromised patients. Materials and Methods: A total of 100 patients were selected for the study. These patients were divided into four groups of 25 patients each: diabetes mellitus group, chronic renal failure group, liver cirrhosis group and control group. All the selected patients were subjected to a detailed general and intra oral examinations and the relevant data was recorded on a specially designed proforma; salivary analysis was done to know the flow rate, pH, total salivary proteins, sodium, potassium, and LDH levels. Results: From the findings, it can be inferred that salivary changes namely changes in salivary pH, salivary flow rates, salivary sodium, salivary potassium, salivary total proteins, and salivary lactate dehydrogenase are significant in medically compromised patients namely uncontrolled diabetes mellitus, chronic renal failure, cirrhosis of liver compared to the control group. Conclusion: pH of saliva was elevated in chronic renal failure patients. Salivary flow rates and sodium were decreased in diabetes mellitus, chronic renal failure, and cirrhosis of liver patients. There was a significant elevation of salivary potassium in chronic renal failure patients. LDH elevation was significant in uncontrolled diabetes mellitus.

  2. Secure and Trustable Electronic Medical Records Sharing using Blockchain.

    Science.gov (United States)

    Dubovitskaya, Alevtina; Xu, Zhigang; Ryu, Samuel; Schumacher, Michael; Wang, Fusheng

    2017-01-01

    Electronic medical records (EMRs) are critical, highly sensitive private information in healthcare, and need to be frequently shared among peers. Blockchain provides a shared, immutable and transparent history of all the transactions to build applications with trust, accountability and transparency. This provides a unique opportunity to develop a secure and trustable EMR data management and sharing system using blockchain. In this paper, we present our perspectives on blockchain based healthcare data management, in particular, for EMR data sharing between healthcare providers and for research studies. We propose a framework on managing and sharing EMR data for cancer patient care. In collaboration with Stony Brook University Hospital, we implemented our framework in a prototype that ensures privacy, security, availability, and fine-grained access control over EMR data. The proposed work can significantly reduce the turnaround time for EMR sharing, improve decision making for medical care, and reduce the overall cost.

  3. 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.

  4. Medical record management systems: criticisms and new perspectives.

    Science.gov (United States)

    Frénot, S; Laforest, F

    1999-06-01

    The first generation of computerized medical records stored the data as text, but these records did not bring any improvement in information manipulation. The use of a relational database management system (DBMS) has largely solved this problem as it allows for data requests by using SQL. However, this requires data structuring which is not very appropriate to medicine. Moreover, the use of templates and icon user interfaces has introduced a deviation from the paper-based record (still existing). The arrival of hypertext user interfaces has proven to be of interest to fill the gap between the paper-based medical record and its electronic version. We think that further improvement can be accomplished by using a fully document-based system. We present the architecture, advantages and disadvantages of classical DBMS-based and Web/DBMS-based solutions. We also present a document-based solution and explain its advantages, which include communication, security, flexibility and genericity.

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

    Science.gov (United States)

    Carpeggiani, Clara; Macerata, Alberto; Morales, Maria Aurora

    2015-08-01

    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. 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. 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. 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. 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.

  7. No Difference in Psychotropic Medication Use in Cosmetic and General Dermatology Patients.

    Science.gov (United States)

    Hamilton, Heather K; Lilly, Evelyn; Arndt, Kenneth A; Dover, Jeffrey S

    2016-07-01

    Patients presenting for appearance-related concerns are often perceived as being more difficult (ie, more needy, more difficult to satisfy) than patients presenting for medical dermatologic problems. While the reasons for this perception are many, some hypothesize that this may be related to a higher rate of anxiety, depression, or body image issues among these patients. To determine the prevalence of psychotropic medication use in cosmetic dermatology patients compared to the prevalence of such medication use in general dermatology patients. METHODS & The study was a retrospective chart review of female patients, 18 or older, new to a private practice. Exclusion criteria included dermatologic disorders with known psychosocial comorbidity. Psychotropic medication use was recorded. The percentage of subjects in the medical group (n=156) who reported using psychotropic medications was 22.2% compared to 26.8% in the cosmetic group (n=154; P=0.09). The prevalence of psychotropic medication use among all dermatology patients in our practice was relatively high, but there was no statistically significant difference in the rate of psychotropic medication use in cosmetic dermatology patients compared to general dermatology patients. J Drugs Dermatol. 2016;15(7):858-861.

  8. Automated processing of electronic medical records is a reliable method of determining aspirin use in populations at risk for cardiovascular events.

    Science.gov (United States)

    Pakhomov, Serguei Vs; Shah, Nilay D; Hanson, Penny; Balasubramaniam, Saranya C; Smith, Steven A

    2010-01-01

    Low-dose aspirin reduces cardiovascular risk; however, monitoring over-the-counter medication use relies on the time-consuming and costly manual review of medical records. Our objective is to validate natural language processing (NLP) of the electronic medical record (EMR) for extracting medication exposure and contraindication information. The text of EMRs for 499 patients with type 2 diabetes was searched using NLP for evidence of aspirin use and its contraindications. The results were compared to a standardised manual records review. Of the 499 patients, 351 (70%) were using aspirin and 148 (30%) were not, according to manual review. NLP correctly identified 346 of the 351 aspirin-positive and 134 of the 148 aspirin-negative patients, indicating a sensitivity of 99% (95% CI 97-100) and specificity of 91% (95% CI 88-97). Of the 148 aspirin-negative patients, 66 (45%) had contraindications and 82 (55%) did not, according to manual review. NLP search for contraindications correctly identified 61 of the 66 patients with contraindications and 58 of the 82 patients without, yielding a sensitivity of 92% (95% CI 84-97) and a specificity of 71% (95% CI 60-80). NLP of the EMR is accurate in ascertaining documented aspirin use and could potentially be used for epidemiological research as a source of cardiovascular risk factor information.

  9. 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. Copyright © 2014 Elsevier B.V. All rights reserved.

  10. 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.

  11. Nonadministration of medication doses for venous thromboembolism prophylaxis in a cohort of hospitalized patients.

    Science.gov (United States)

    Popoola, Victor O; Lau, Brandyn D; Tan, Esther; Shaffer, Dauryne L; Kraus, Peggy S; Farrow, Norma E; Hobson, Deborah B; Aboagye, Jonathan K; Streiff, Michael B; Haut, Elliott R

    2018-03-15

    Results of a study to characterize patterns of nonadministration of medication doses for venous thromboembolism (VTE) prevention among hospitalized patients are presented. The electronic records of all patients admitted to 4 floors of a medical center during a 1-month period were examined to identify patients whose records indicated at least 1 nonadministered dose of medication for VTE prophylaxis. Proportions of nonadministered doses by medication type, intended route of administration, and VTE risk categorization were compared; reasons for nonadministration were evaluated. Overall, 12.7% of all medication doses prescribed to patients in the study cohort ( n = 75) during the study period (857 of 6,758 doses in total) were not administered. Nonadministration of 1 or more doses of VTE prophylaxis medication was nearly twice as likely for subcutaneous anticoagulants than for all other medication types (231 of 1,112 doses [20.8%] versus 626 of 5,646 doses [11.2%], p < 0.001). For all medications prescribed, the most common reason for nonadministration was patient refusal (559 of 857 doses [65.2%]); the refusal rate was higher for subcutaneous anticoagulants than for all other medication categories (82.7% versus 58.8%, p < 0.001). Doses of antiretrovirals, immunosuppressives, antihypertensives, psychiatric medications, analgesics, and antiepileptics were less commonly missed than doses of electrolytes, vitamins, and gastrointestinal medications. Scheduled doses of subcutaneous anticoagulants for hospitalized patients were more likely to be missed than doses of all other medication types. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  12. A search algorithm for identifying likely users and non-users of marijuana from the free text of the electronic medical record.

    Directory of Open Access Journals (Sweden)

    Salomeh Keyhani

    Full Text Available The harmful effects of marijuana on health and in particular cardiovascular health are understudied. To develop such knowledge, an efficient method of developing an informative cohort of marijuana users and non-users is needed.We identified patients with a diagnosis of coronary artery disease using ICD-9 codes who were seen in the San Francisco VA in 2015. We imported these patients' medical record notes into an informatics platform that facilitated text searches. We categorized patients into those with evidence of marijuana use in the past 12 months and patients with no such evidence, using the following text strings: "marijuana", "mjx", and "cannabis". We randomly selected 51 users and 51 non-users based on this preliminary classification, and sent a recruitment letter to 97 of these patients who had contact information available. Patients were interviewed on marijuana use and domains related to cardiovascular health. Data on marijuana use collected from the medical record was compared to data collected as part of the interview.The interview completion rate was 71%. Among the 35 patients identified by text strings as having used marijuana in the previous year, 15 had used marijuana in the past 30 days (positive predictive value = 42.9%. The probability of use in the past month increased from 8.8% to 42.9% in people who have these keywords in their medical record compared to those who did not have these terms in their medical record.Methods that combine text search strategies for participant recruitment with health interviews provide an efficient approach to developing prospective cohorts that can be used to study the health effects of marijuana.

  13. Characteristics of registration of medical records in a hospital in southern Peru

    Directory of Open Access Journals (Sweden)

    Cender Udai Quispe-Juli

    2016-04-01

    Full Text Available Objective: To determine the characteristics of registration of medical records of hospitalization in the Hospital III Yanahuara in Arequipa, Peru. Material and methods: The study was observational, cross-sectional and retrospective. 225 medical records of hospitalization were evaluated in November 2015. A tab consisting of 15 items was used; each item was assessed using a scale: "very bad", "bad", "acceptable", "good" and "very good". Adescriptive analysis was done by calculating frequency. Results: Items with a higher proportion of acceptable registration data were: clear therapeutic indication (84%, clinical evolution (74.7%, diagnosis (70.7%, complete and orderly therapeutic indication (54.2%, medical history taking (50.2% and physical examination (43.1%. The very well recorded items were: indication of tests and procedures (97.3%, medical identification (91.1% and allergies (67.1%. Very bad recorded items were: reason for admission (91.1%, life habits (72.9% and prior treatment (38.2%. Conclusions: Most medical records of hospitalization are characterized by an acceptable record of most evaluated items; however they have notable deficiencies in some items.

  14. Effects of scanning and eliminating paper-based medical records on hospital physicians' clinical work practice.

    Science.gov (United States)

    Laerum, Hallvard; Karlsen, Tom H; Faxvaag, Arild

    2003-01-01

    It is not automatically given that the paper-based medical record can be eliminated after the introduction of an electronic medical record (EMR) in a hospital. Many keep and update the paper-based counterpart, and this limits the use of the EMR system. The authors have evaluated the physicians' clinical work practices and attitudes toward a system in a hospital that has eliminated the paper-based counterpart using scanning technology. Combined open-ended interviews (8 physicians) and cross-sectional survey (70 physicians) were conducted and compared with reference data from a previous national survey (69 physicians from six hospitals). The hospitals in the reference group were using the same EMR system without the scanning module. The questionnaire (English translation available as an online data supplement at ) covered frequency of use of the EMR system for 19 defined tasks, ease of performing them, and user satisfaction. The interviews were open-ended. The physicians routinely used the system for nine of 11 tasks regarding retrieval of patient data, which the majority of the physicians found more easily performed than before. However, 22% to 25% of the physicians found retrieval of patient data more difficult, particularly among internists (33%). Overall, the physicians were equally satisfied with the part of the system handling the regular electronic data as that of the physicians in the reference group. They were, however, much less satisfied with the use of scanned document images than that of regular electronic data, using the former less frequently than the latter. Scanning and elimination of the paper-based medical record is feasible, but the scanned document images should be considered an intermediate stage toward fully electronic medical records. To our knowledge, this is the first assessment from a hospital in the process of completing such a scanning project.

  15. Scale-up of networked HIV treatment in Nigeria: creation of an integrated electronic medical records system.

    Science.gov (United States)

    Chaplin, Beth; Meloni, Seema; Eisen, Geoffrey; Jolayemi, Toyin; Banigbe, Bolanle; Adeola, Juliette; Wen, Craig; Reyes Nieva, Harry; Chang, Charlotte; Okonkwo, Prosper; Kanki, Phyllis

    2015-01-01

    The implementation of PEPFAR programs in resource-limited settings was accompanied by the need to document patient care on a scale unprecedented in environments where paper-based records were the norm. We describe the development of an electronic medical records system (EMRS) put in place at the beginning of a large HIV/AIDS care and treatment program in Nigeria. Databases were created to record laboratory results, medications prescribed and dispensed, and clinical assessments, using a relational database program. A collection of stand-alone files recorded different elements of patient care, linked together by utilities that aggregated data on national standard indicators and assessed patient care for quality improvement, tracked patients requiring follow-up, generated counts of ART regimens dispensed, and provided 'snapshots' of a patient's response to treatment. A secure server was used to store patient files for backup and transfer. By February 2012, when the program transitioned to local in-country management by APIN, the EMRS was used in 33 hospitals across the country, with 4,947,433 adult, pediatric and PMTCT records that had been created and continued to be available for use in patient care. Ongoing trainings for data managers, along with an iterative process of implementing changes to the databases and forms based on user feedback, were needed. As the program scaled up and the volume of laboratory tests increased, results were produced in a digital format, wherever possible, that could be automatically transferred to the EMRS. Many larger clinics began to link some or all of the databases to local area networks, making them available to a larger group of staff members, or providing the ability to enter information simultaneously where needed. The EMRS improved patient care, enabled efficient reporting to the Government of Nigeria and to U.S. funding agencies, and allowed program managers and staff to conduct quality control audits. Copyright © 2014

  16. Quality of medication information in discharge summaries from hospitals: an audit of electronic patient records.

    Science.gov (United States)

    Garcia, Beate Hennie; Djønne, Berit Svendsen; Skjold, Frode; Mellingen, Ellen Marie; Aag, Trine Iversen

    2017-12-01

    Background Low quality of medication information in discharge summaries from hospitals may jeopardize optimal therapy and put the patient at risk for medication errors and adverse drug events. Objective To audit the quality of medication information in discharge summaries and explore factors associated with the quality. Setting Helgelandssykehuset Mo i Rana, a rural hospital in central Norway. Method For each month in 2013, we randomly selected 60 discharge summaries from the Department of Medicine and Surgery (totally 720) and evaluated the medication information using eight Norwegian quality criteria. Main outcome measure Mean score per discharge summary ranging from 0 (lowest quality) to 16 (highest quality). Results Mean score per discharge summary was 7.4 (SD 2.8; range 0-14), significantly higher when evaluating medications used regularly compared to mediations used as needed (7.80 vs. 6.52; p < 0.001). Lowest score was achieved for quality criteria concerning generic names, indications for medication use, reasons why changes had been made and information about the source for information. Factors associated with increased quality scores are increasing numbers of medications and male patients. Increasing age seemed to be associated with a reduced score, while type of department was not associated with the quality. Conclusion In discharge summaries from 2013, we identified a low quality of medication information in accordance with the Norwegian quality criteria. Actions for improvement are necessary and follow-up studies to monitor quality are needed.

  17. PASTE: patient-centered SMS text tagging in a medication management system.

    Science.gov (United States)

    Stenner, Shane P; Johnson, Kevin B; Denny, Joshua C

    2012-01-01

    To evaluate the performance of a system that extracts medication information and administration-related actions from patient short message service (SMS) messages. Mobile technologies provide a platform for electronic patient-centered medication management. MyMediHealth (MMH) is a medication management system that includes a medication scheduler, a medication administration record, and a reminder engine that sends text messages to cell phones. The object of this work was to extend MMH to allow two-way interaction using mobile phone-based SMS technology. Unprompted text-message communication with patients using natural language could engage patients in their healthcare, but presents unique natural language processing challenges. The authors developed a new functional component of MMH, the Patient-centered Automated SMS Tagging Engine (PASTE). The PASTE web service uses natural language processing methods, custom lexicons, and existing knowledge sources to extract and tag medication information from patient text messages. A pilot evaluation of PASTE was completed using 130 medication messages anonymously submitted by 16 volunteers via a website. System output was compared with manually tagged messages. Verified medication names, medication terms, and action terms reached high F-measures of 91.3%, 94.7%, and 90.4%, respectively. The overall medication name F-measure was 79.8%, and the medication action term F-measure was 90%. Other studies have demonstrated systems that successfully extract medication information from clinical documents using semantic tagging, regular expression-based approaches, or a combination of both approaches. This evaluation demonstrates the feasibility of extracting medication information from patient-generated medication messages.

  18. An analytical approach to characterize morbidity profile dissimilarity between distinct cohorts using electronic medical records.

    Science.gov (United States)

    Schildcrout, Jonathan S; Basford, Melissa A; Pulley, Jill M; Masys, Daniel R; Roden, Dan M; Wang, Deede; Chute, Christopher G; Kullo, Iftikhar J; Carrell, David; Peissig, Peggy; Kho, Abel; Denny, Joshua C

    2010-12-01

    We describe a two-stage analytical approach for characterizing morbidity profile dissimilarity among patient cohorts using electronic medical records. We capture morbidities using the International Statistical Classification of Diseases and Related Health Problems (ICD-9) codes. In the first stage of the approach separate logistic regression analyses for ICD-9 sections (e.g., "hypertensive disease" or "appendicitis") are conducted, and the odds ratios that describe adjusted differences in prevalence between two cohorts are displayed graphically. In the second stage, the results from ICD-9 section analyses are combined into a general morbidity dissimilarity index (MDI). For illustration, we examine nine cohorts of patients representing six phenotypes (or controls) derived from five institutions, each a participant in the electronic MEdical REcords and GEnomics (eMERGE) network. The phenotypes studied include type II diabetes and type II diabetes controls, peripheral arterial disease and peripheral arterial disease controls, normal cardiac conduction as measured by electrocardiography, and senile cataracts. Copyright © 2010 Elsevier Inc. All rights reserved.

  19. Usability Evaluation of An Electronic Medication Administration Record (eMAR) Application

    Science.gov (United States)

    Guo, J.; Iribarren, S.; Kapsandoy, S.; Perri, S.; Staggers, N.

    2011-01-01

    Background Electronic medication administration records (eMARs) have been widely used in recent years. However, formal usability evaluations are not yet available for these vendor applications, especially from the perspective of nurses, the largest group of eMAR users. Objective To conduct a formal usability evaluation of an implemented eMAR. Methods Four evaluators examined a commercial vendor eMAR using heuristic evaluation techniques. The evaluators defined seven tasks typical of eMAR use and independently evaluated the application. Consensus techniques were used to obtain 100% agreement of identified usability problems and severity ratings. Findings were reviewed with 5 clinical staff nurses and the Director of Clinical Informatics who verified findings with a small group of clinical nurses. Results Evaluators found 60 usability problems categorized into 233 heuristic violations. Match, Error, and Visibility heuristics were the most frequently violated. Administer Medication and Order and Modify Medications tasks had the highest number of heuristic violations and usability problems rated as major or catastrophic. Conclusion The high number of usability problems could impact the effectiveness, efficiency and satisfaction of nurses’ medication administration activities and may include concerns about patient safety. Usability is a joint responsibility between sites and vendors. We offer a call to action for usability evaluations at all sites and eMAR application redesign as necessary to improve the user experience and promote patient safety. PMID:23616871

  20. Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature.

    Science.gov (United States)

    Simons, Sereh M J; Cillessen, Felix H J M; Hazelzet, Jan A

    2016-08-02

    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 with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR). Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR. On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements. In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability. Two main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing

  1. Views on health information sharing and privacy from primary care practices using electronic medical records.

    Science.gov (United States)

    Perera, Gihan; Holbrook, Anne; Thabane, Lehana; Foster, Gary; Willison, Donald J

    2011-02-01

    To determine how patients and physicians balance the perceived benefits and harms of sharing electronic health data for patient care and for secondary purposes. Before-after survey of patients and providers in practices using electronic medical records (EMRs) enrolled in a clinical trial in Ontario, Canada. Outcomes were measured using the Health Information Privacy Questionnaire (HIPQ) at baseline and end of study. Thirteen questions in 4 general domains investigated attitudes towards the privacy of EMRs, outsider's use of patient's health information, the sharing of patient's information within the health care system, and the overall perception of benefits versus harms of computerization in health care. 511 patients (mean age 60.3 years, 49.6% female) and 46 physicians (mean age 47.2 years, 37.0% female) participated. Most (>90%) supported the computerized sharing of the patient's health records among their health care professionals and to provide clinical advice. Fewer agreed that the patient's de-identified information should be shared outside of the health care circle (records can be keep more private than paper records (38-50%). Overall, a majority (58% patients, 70% physicians) believed that the benefits of computerization were greater than the risks of confidentiality loss. This was especially true for patients who were frequent computer users. While these primary care physicians and their patients valued the clinical features of EMRs, a substantial minority have concerns about the secondary use of de-identified information. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

  2. Medical impacts of anthropometric records. | Adebisi | Annals of ...

    African Journals Online (AJOL)

    Anthropology is now one of the inter-disciplinary scientific fields that is gaining much attention in forensic, socio-cultural, industrial and bio-medical applications. There is a need for a better awareness of some of the impacts - past and present, in the medical practice, of the records that were obtained by workers in this field in ...

  3. [Medication reconciliation at hospital admission: Results and identification of target patients].

    Science.gov (United States)

    San José Ruiz, B; Serrano De Lucas, L; López-Giménez, L R; Baza Martínez, B; Sautua Larreategi, S; Bustinza Txertudi, A; Sebastián Leza, Á; Chirivella Ramón, M T; Fonseca Legrand, J L; de Miguel Cascon, M

    2016-06-01

    To quantify and to classify the discrepancies between the admission treatment and the usual patient treatment. To determine the variables that predict those patients that will have more benefit from medication reconciliation. A prospective medication reconciliation study was conducted in the Vascular Surgery Unit from March 2014 to December 2014. When the patients were admitted to the Vascular Surgery Unit, they were informed about the study and asked to prepare information about their chronic treatment. The pharmacist then checked their clinical records, outpatient prescriptions, and also interviewed the patient, obtaining the best pharmacotherapeutic history available. The discrepancies with the admission treatment were written into the patient electronic clinical records. Finally, the physician classified the discrepancies, and changed the treatment, if needed. The statistical analysis included a comparison between patients with and without a non-justified discrepancy (NJD). The statistically different characteristics were used to plot Receiver Operating Characteristic curves, in order to determine the sensitivity and the specificity of these variables to select patients with discrepancies. A total of 380 patients were included. There were 845 non-justified, 600 justified non-documented, and 439 justified documented discrepancies. At least one NJD was identified in 293 patients (77%), with 65 patients (17%) having only justified discrepancies, and 22 patients (6%) having no discrepancies. NJD were: different dose, route or schedule (51%), omission (39%), wrong drug (8%) and commission (2%). The variables associated with discrepancies were number of chronic medications drugs and provider of information. In most studies, omission is the most frequent error. In contrast, in our study the most frequent error is different dose, route, or schedule. The variable that allows selecting patients at higher risk of discrepancies is the number of chronic drugs. This risk is

  4. The Electronic Health Record Objective Structured Clinical Examination: Assessing Student Competency in Patient Interactions While Using the Electronic Health Record.

    Science.gov (United States)

    Biagioli, Frances E; Elliot, Diane L; Palmer, Ryan T; Graichen, Carla C; Rdesinski, Rebecca E; Ashok Kumar, Kaparaboyna; Galper, Ari B; Tysinger, James W

    2017-01-01

    Because many medical students do not have access to electronic health records (EHRs) in the clinical environment, simulated EHR training is necessary. Explicitly training medical students to use EHRs appropriately during patient encounters equips them to engage patients while also attending to the accuracy of the record and contributing to a culture of information safety. Faculty developed and successfully implemented an EHR objective structured clinical examination (EHR-OSCE) for clerkship students at two institutions. The EHR-OSCE objectives include assessing EHR-related communication and data management skills. The authors collected performance data for students (n = 71) at the first institution during academic years 2011-2013 and for students (n = 211) at the second institution during academic year 2013-2014. EHR-OSCE assessment checklist scores showed that students performed well in EHR-related communication tasks, such as maintaining eye contact and stopping all computer work when the patient expresses worry. Findings indicated student EHR skill deficiencies in the areas of EHR data management including medical history review, medication reconciliation, and allergy reconciliation. Most students' EHR skills failed to improve as the year progressed, suggesting that they did not gain the EHR training and experience they need in clinics and hospitals. Cross-institutional data comparisons will help determine whether differences in curricula affect students' EHR skills. National and institutional policies and faculty development are needed to ensure that students receive adequate EHR education, including hands-on experience in the clinic as well as simulated EHR practice.

  5. History of the Rochester Epidemiology Project: half a century of medical records linkage in a US population.

    Science.gov (United States)

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

    2012-12-01

    The Rochester Epidemiology Project (REP) has maintained a comprehensive medical records linkage system for nearly half a century for almost all persons residing in Olmsted County, Minnesota. Herein, we provide a brief history of the REP before and after 1966, the year in which the REP was officially established. The key protagonists before 1966 were Henry Plummer, Mabel Root, and Joseph Berkson, who developed a medical records linkage system at Mayo Clinic. In 1966, Leonard Kurland established collaborative agreements with other local health care providers (hospitals, physician groups, and clinics [primarily Olmsted Medical Center]) to develop a medical records linkage system that covered the entire population of Olmsted County, and he obtained funding from the National Institutes of Health to support the new system. In 1997, L. Joseph Melton III addressed emerging concerns about the confidentiality of medical record information by introducing a broad patient research authorization as per Minnesota state law. We describe how the key protagonists of the REP have responded to challenges posed by evolving medical knowledge, information technology, and public expectation and policy. In addition, we provide a general description of the system; discuss issues of data quality, reliability, and validity; describe the research team structure; provide information about funding; and compare the REP with other medical information systems. The REP can serve as a model for the development of similar research infrastructures in the United States and worldwide. Copyright © 2012 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

  6. Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial

    Directory of Open Access Journals (Sweden)

    James F. Graumlich

    2016-01-01

    Full Text Available Among patients with various levels of health literacy, the effects of collaborative, patient-provider, medication-planning tools on outcomes relevant to self-management are uncertain. Objective. Among adult patients with type II diabetes mellitus, we tested the effectiveness of a medication-planning tool (Medtable™ implemented via an electronic medical record to improve patients’ medication knowledge, adherence, and glycemic control compared to usual care. Design. A multicenter, randomized controlled trial in outpatient primary care clinics. 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months. Results. Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications. Patients’ knowledge of drug indication improved with Medtable regardless of their literacy status. However, Medtable did not improve patients’ demonstrated medication use, regimen adherence, or glycemic control (HbA1c. Conclusion. The Medtable tool supported provider/patient collaboration related to medication use, as reflected in patient satisfaction with communication, but had limited impact on patient medication knowledge, adherence, and HbA1c outcomes. This trial is registered with ClinicalTrials.gov NCT01296633.

  7. Beneficial Effects of Two Types of Personal Health Record Services Connected With Electronic Medical Records Within the Hospital Setting.

    Science.gov (United States)

    Lee, Jisan; Kim, James G Boram; Jin, Meiling; Ahn, Kiwhan; Kim, Byungjun; Kim, Sukwha; Kim, Jeongeun

    2017-11-01

    Healthcare consumers must be able to make decisions based on accurate health information. To assist with this, we designed and developed an integrated system connected with electronic medical records in hospitals to ensure delivery of accurate health information. The system-called the Consumer-centered Open Personal Health Record platform-is composed of two services: a portal for users with any disease and a mobile application for users with cleft lip/palate. To assess the benefits of these services, we used a quasi-experimental, pretest-posttest design, assigning participants to the portal (n = 50) and application (n = 52) groups. Both groups showed significantly increased knowledge, both objective (actual knowledge of health information) and subjective (perceived knowledge of health information), after the intervention. Furthermore, while both groups showed higher information needs satisfaction after the intervention, the application group was significantly more satisfied. Knowledge changes were more affected by participant characteristics in the application group. Our results may be due to the application's provision of specific disease information and a personalized treatment plan based on the participant and other users' data. We recommend that services connected with electronic medical records target specific diseases to provide personalized health management to patients in a hospital setting.

  8. Patient safety in out-of-hours primary care: a review of patient records

    Directory of Open Access Journals (Sweden)

    Wensing Michel

    2010-12-01

    Full Text Available Abstract Background Most patients receive healthcare in primary care settings, but relatively little is known about patient safety. Out-of-hours contacts are of particular importance to patient safety. Our aim was to examine the incidence, types, causes, and consequences of patient safety incidents at general practice cooperatives for out-of-hours primary care and to examine which factors were associated with the occurrence of patient safety incidents. Methods A retrospective study of 1,145 medical records concerning patient contacts with four general practice cooperatives. Reviewers identified records with evidence of a potential patient safety incident; a physician panel determined whether a patient safety incident had indeed occurred. In addition, the panel determined the type, causes, and consequences of the incidents. Factors associated with incidents were examined in a random coefficient logistic regression analysis. Results In 1,145 patient records, 27 patient safety incidents were identified, an incident rate of 2.4% (95% CI: 1.5% to 3.2%. The most frequent incident type was treatment (56%. All incidents had at least partly been caused by failures in clinical reasoning. The majority of incidents did not result in patient harm (70%. Eight incidents had consequences for the patient, such as additional interventions or hospitalisation. The panel assessed that most incidents were unlikely to result in patient harm in the long term (89%. Logistic regression analysis showed that age was significantly related to incident occurrence: the likelihood of an incident increased with 1.03 for each year increase in age (95% CI: 1.01 to 1.04. Conclusion Patient safety incidents occur in out-of-hours primary care, but most do not result in harm to patients. As clinical reasoning played an important part in these incidents, a better understanding of clinical reasoning and guideline adherence at GP cooperatives could contribute to patient safety.

  9. Identifying Risk of Future Asthma Attacks Using UK Medical Record Data : A Respiratory Effectiveness Group Initiative

    NARCIS (Netherlands)

    Blakey, John D.; Price, David B.; Pizzichini, Emilio; Popov, Todor A.; Dimitrov, Borislav D.; Postma, Dirkje S.; Josephs, Lynn K.; Kaplan, Alan; Papi, Alberto; Kerkhof, Marjan; Hillyer, Elizabeth V.; Chisholm, Alison; Thomas, Mike

    BACKGROUND: Asthma attacks are common, serious, and costly. Individual factors associated with attacks, such as poor symptom control, are not robust predictors. OBJECTIVE: We investigated whether the rich data available in UK electronic medical records could identify patients at risk of recurrent

  10. Ethnicity Recording in Primary Care Computerised Medical Record Systems: An Ontological Approach

    Directory of Open Access Journals (Sweden)

    Zayd Tippu

    2017-03-01

    Full Text Available Background Ethnicity recording within primary care computerised medical record (CMR systems is suboptimal, exacerbated by tangled taxonomies within current coding systems. Objective To develop a method for extending ethnicity identification using routinely collected data. Methods We used an ontological method to maximise the reliability and prevalence of ethnicity information in the Royal College of General Practitioner’s Research and Surveillance database. Clinical codes were either directly mapped to ethnicity group or utilised as proxy markers (such as language spoken from which ethnicity could be inferred. We compared the performance of our method with the recording rates that would be identified by code lists utilised by the UK pay for the performance system, with the help of the Quality and Outcomes Framework (QOF. Results Data from 2,059,453 patients across 110 practices were included. The overall categorisable ethnicity using QOF codes was 36.26% (95% confidence interval (CI: 36.20%–36.33%. This rose to 48.57% (CI:48.50%–48.64% using the described ethnicity mapping process. Mapping increased across all ethnic groups. The largest increase was seen in the white ethnicity category (30.61%; CI: 30.55%–30.67% to 40.24%; CI: 40.17%–40.30%. The highest relative increase was in the ethnic group categorised as the other (0.04%; CI: 0.03%–0.04% to 0.92%; CI: 0.91%–0.93%. Conclusions This mapping method substantially increases the prevalence of known ethnicity in CMR data and may aid future epidemiological research based on routine data.

  11. Worldwide telemedicine services based on distributed multimedia electronic patient records by using the second generation Web server hyperwave.

    Science.gov (United States)

    Quade, G; Novotny, J; Burde, B; May, F; Beck, L E; Goldschmidt, A

    1999-01-01

    A distributed multimedia electronic patient record (EPR) is a central component of a medicine-telematics application that supports physicians working in rural areas of South America, and offers medical services to scientists in Antarctica. A Hyperwave server is used to maintain the patient record. As opposed to common web servers--and as a second generation web server--Hyperwave provides the capability of holding documents in a distributed web space without the problem of broken links. This enables physicians to browse through a patient's record by using a standard browser even if the patient's record is distributed over several servers. The patient record is basically implemented on the "Good European Health Record" (GEHR) architecture.

  12. DIGITAL ONCOLOGY PATIENT RECORD - HETEROGENEOUS FILE BASED APPROACH

    Directory of Open Access Journals (Sweden)

    Nikolay Sapundzhiev

    2010-12-01

    Full Text Available Introduction: Oncology patients need extensive follow-up and meticulous documentation. The aim of this study was to introduce a simple, platform independent file based system for documentation of diagnostic and therapeutic procedures in oncology patients and test its function.Material and methods: A file-name based system of the type M1M2M3.F2 was introduced, where M1 is a unique identifier for the patient, M2 is the date of the clinical intervention/event, M3 is an identifier for the author of the medical record and F2 is the specific software generated file-name extension.Results: This system is in use at 5 institutions, where a total of 11 persons on 14 different workstations inputted 16591 entries (files for 2370. The merge process was tested on 2 operating systems - when copied together all files sort up as expected by patient, and for each patient in a chronological order, providing a digital cumulative patient record, which contains heterogeneous file formats.Conclusion: The file based approach for storing heterogeneous digital patient related information is an reliable system, which can handle open-source, proprietary, general and custom file formats and seems to be easily scalable. Further development of software for automatic checks of the integrity and searching and indexing of the files is expected to produce a more user-friendly environment

  13. 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.

  14. 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.

  15. 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.

  16. Insufficiency of Medical Care for Patients with Acute Respiratory Failure

    Directory of Open Access Journals (Sweden)

    A. V. Dats

    2017-01-01

    Full Text Available The purpose of the research: to analyze insufficiency of medical care for patients with acute respiratory failure in the ICU.Materials and methods. It was a retrospective study of 160 patients' medical records (age from 15 to 84 years with acute respiratory failure (ARF hospitalized in the ICUs of 24 regional and municipal hospitals of the Irkutsk Oblast. Medical records were provided by the Territorial Fund of Compulsory Medical Insurance of citizens of Irkutsk region.The results. The basic defects in conducting mechanical ventilation were associated with improper lung function evaluation, microbiological tests of sputum and radiology. ARF was not diagnosed in 32 of 160 ICU patients (20%. In 23% of cases the causes of ARF were not diagnosed. The greatest part of the defects in the treatment of patients with acute respiratory failure was found during the treatment of hypoxemia: no recovery of the respiratory tract patency, no prescription of oxygen for hypoxemia, no mechanical ventilation for persistent hypoxemia on the background of maximum oxygen supply and late switching to mechanical ventilation at the stage of hypoxic cardiac arrest.Conclusions. The use of pulse oximetry alone in the absence of arterial blood gas analysis in 98% of patients with acute respiratory failure and failure to perform the lung X-ray and/or MSCT imaging in 21% of patients were accompanied by a high level of undiagnosed acute respiratory distress syndrome (78%, lung contusion (60%, pulmonary embolism (40%, cardiogenic pulmonary edema (33%, and nosocomial pneumonia (28%. Defects of treatment of patients with ARF in 46% of cases were caused by inadequate management of hypoxemia associated with the recovery of the respiratory tract patency, prescription of oxygen, and mechanical ventilation. 

  17. NEED ANALYSIS FOR IDENTIFYING ESP MATERIALS FOR MEDICAL RECORD STUDENTS IN APIKES CITRA MEDIKA SURAKARTA

    Directory of Open Access Journals (Sweden)

    Beta Setiawati

    2016-06-01

    and quantitative methods. The outcomesof this study showed the real necessities of students in learning English to prepare their future at the field of medical record and health information. Findings of the need analysis demonstrate that all four of the language skills were necessary for their academic studies and their target career. There are certain topics related to English for medical record such as medical record staff’ duties, ethical and legal issues in medical record, Hospital statistics, Medical record filling system, Health information system, and so on. Accordingly, this study proposes new ESP materials based on the stakeholders’ needs.It is suggested that textbook or handout of English for Medical Record will be made based on the Need Analysis by ESP designers and ESP lecturers involve actively recognizing the progressive needs of medical record students.

  18. 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 pancreas volume normalized by subject body weight, body mass index, or body surface area (all P 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

  19. Patients' Non-Medical Characteristics Contribute to Collective Medical Decision-Making at Multidisciplinary Oncological Team Meetings.

    Science.gov (United States)

    Restivo, Léa; Apostolidis, Thémis; Bouhnik, Anne-Déborah; Garciaz, Sylvain; Aurran, Thérèse; Julian-Reynier, Claire

    2016-01-01

    The contribution of patients' non-medical characteristics to individual physicians' decision-making has attracted considerable attention, but little information is available on this topic in the context of collective decision-making. Medical decision-making at cancer centres is currently carried out using a collective approach, at MultiDisciplinary Team (MDT) meetings. The aim of this study was to determine how patients' non-medical characteristics are presented at MDT meetings and how this information may affect the team's final medical decisions. Observations were conducted at a French Cancer Centre during MDT meetings at which non-standard cases involving some uncertainty were discussed from March to May 2014. Physicians' verbal statements and predefined contextual parameters were collected with a non-participant observational approach. Non numerical data collected in the form of open notes were then coded for quantitative analysis. Univariate and multivariate statistical analyses were performed. In the final sample of patients' records included and discussed (N = 290), non-medical characteristics were mentioned in 32.8% (n = 95) of the cases. These characteristics corresponded to demographics in 22.8% (n = 66) of the cases, psychological data in 11.7% (n = 34), and relational data in 6.2% (n = 18). The patient's age and his/her "likeability" were the most frequently mentioned characteristics. In 17.9% of the cases discussed, the final decision was deferred: this outcome was positively associated with the patients' non-medical characteristics and with uncertainty about the outcome of the therapeutic options available. The design of the study made it difficult to draw definite cause-and-effect conclusions. The Social Representations approach suggests that patients' non-medical characteristics constitute a kind of tacit professional knowledge that may be frequently mobilised in physicians' everyday professional practice. The links observed between patients

  20. Review by a local medical research ethics committee of the conduct of approved research projects, by examination of patients' case notes, consent forms, and research records and by interview.

    OpenAIRE

    Smith, T.; Moore, E. J.; Tunstall-Pedoe, H.

    1997-01-01

    OBJECTIVE: To monitor the conduct of medical research projects that have already been approved by the local medical research ethics committee. DESIGN: Follow up study of ethically approved studies (randomly selected from all the studies approved in the previous year) by examination of patients' case notes, consent forms, and research records and by interview of the researchers at their workplace. SETTING: Tayside, Scotland (mixed rural and urban population). SUBJECTS: 30 research projects app...

  1. Genetic databases and consent for use of medical records

    NARCIS (Netherlands)

    Gevers, J. K. M.

    2004-01-01

    The legislation on the Icelandic genetic database provides for an opting-out system for the collection of encoded medical information from individual medical records. From the beginning this has raised criticism, in Iceland itself and abroad. The Supreme Court has now decided that this approach of

  2. Electronic health record training in undergraduate medical education: bridging theory to practice with curricula for empowering patient- and relationship-centered care in the computerized setting.

    Science.gov (United States)

    Wald, Hedy S; George, Paul; Reis, Shmuel P; Taylor, Julie Scott

    2014-03-01

    While electronic health record (EHR) use is becoming state-of-the-art, deliberate teaching of health care information technology (HCIT) competencies is not keeping pace with burgeoning use. Medical students require training to become skilled users of HCIT, but formal pedagogy within undergraduate medical education (UME) is sparse. How can medical educators best meet the needs of learners while integrating EHRs into medical education and practice? How can they help learners preserve and foster effective communication skills within the computerized setting? In general, how can UME curricula be devised for skilled use of EHRs to enhance rather than hinder provision of effective, humanistic health care?Within this Perspective, the authors build on recent publications that "set the stage" for next steps: EHR curricula innovation and implementation as concrete embodiments of theoretical underpinnings. They elaborate on previous calls for maximizing benefits and minimizing risks of EHR use with sufficient focus on physician-patient communication skills and for developing core competencies within medical education. The authors describe bridging theory into practice with systematic longitudinal curriculum development for EHR training in UME at their institution, informed by Kern and colleagues' curriculum development framework, narrative medicine, and reflective practice. They consider this innovation within a broader perspective-the overarching goal of empowering undergraduate medical students' patient- and relationship-centered skills while effectively demonstrating HCIT-related skills.

  3. Agreement between hospital discharge diagnosis codes and medical records to identify metastatic colorectal cancer and associated comorbidities in elderly patients.

    Science.gov (United States)

    Gouverneur, A; Dolatkhani, D; Rouyer, M; Grelaud, A; Francis, F; Gilleron, V; Fourrier-Réglat, A; Noize, P

    2017-08-01

    Quality of coding to identify cancers and comorbidities through the French hospital diagnosis database (Programme de médicalisation des systèmes d'information, PMSI) has been little investigated. Agreement between medical records and PMSI database was evaluated regarding metastatic colorectal cancer (mCRC) and comorbidities. From 01/01/2013 to 06/30/2014, 74 patients aged≥65years at mCRC diagnosis were identified in Bordeaux teaching hospital. Data on mCRC and comorbidities were collected from medical records. All diagnosis codes (main, related and associated) registered into the PMSI were extracted. Agreement between sources was evaluated using the percent agreement for mCRC and the kappa (κ) statistic for comorbidities. Agreement for primary CRC and mCRC was higher using all types of diagnosis codes instead of the main one exclusively (respectively 95% vs. 53% for primary CRC and 91% vs. 24% for mCRC). Agreement was substantial (κ 0.65) for cardiovascular diseases, notably atrial fibrillation (κ 0.77) and hypertension (κ 0.68). It was moderate for psychiatric disorders (κ 0.49) and respiratory diseases (κ 0.48), although chronic obstructive pulmonary disease had a good agreement (κ 0.75). Within the class of endocrine, nutritional and metabolic diseases (κ 0.55), agreement was substantial for diabetes (κ 0.91), obesity (κ 0.82) and hypothyroidism (κ 0.72) and moderate for hypercholesterolemia (κ 0.51) and malnutrition (κ 0.42). These results are reassuring with regard to detection through PMSI of mCRC if all types of diagnosis codes are considered and useful to better choose comorbidities in elderly mCRC patients that could be well identified through hospital diagnosis codes. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

  4. A shared computer-based problem-oriented patient record for the primary care team.

    Science.gov (United States)

    Linnarsson, R; Nordgren, K

    1995-01-01

    1. INTRODUCTION. A computer-based patient record (CPR) system, Swedestar, has been developed for use in primary health care. The principal aim of the system is to support continuous quality improvement through improved information handling, improved decision-making, and improved procedures for quality assurance. The Swedestar system has evolved during a ten-year period beginning in 1984. 2. SYSTEM DESIGN. The design philosophy is based on the following key factors: a shared, problem-oriented patient record; structured data entry based on an extensive controlled vocabulary; advanced search and query functions, where the query language has the most important role; integrated decision support for drug prescribing and care protocols and guidelines; integrated procedures for quality assurance. 3. A SHARED PROBLEM-ORIENTED PATIENT RECORD. The core of the CPR system is the problem-oriented patient record. All problems of one patient, recorded by different members of the care team, are displayed on the problem list. Starting from this list, a problem follow-up can be made, one problem at a time or for several problems simultaneously. Thus, it is possible to get an integrated view, across provider categories, of those problems of one patient that belong together. This shared problem-oriented patient record provides an important basis for the primary care team work. 4. INTEGRATED DECISION SUPPORT. The decision support of the system includes a drug prescribing module and a care protocol module. The drug prescribing module is integrated with the patient records and includes an on-line check of the patient's medication list for potential interactions and data-driven reminders concerning major drug problems. Care protocols have been developed for the most common chronic diseases, such as asthma, diabetes, and hypertension. The patient records can be automatically checked according to the care protocols. 5. PRACTICAL EXPERIENCE. The Swedestar system has been implemented in a

  5. Disease Heritability Inferred from Familial Relationships Reported in Medical Records.

    Science.gov (United States)

    Polubriaginof, Fernanda C G; Vanguri, Rami; Quinnies, Kayla; Belbin, Gillian M; Yahi, Alexandre; Salmasian, Hojjat; Lorberbaum, Tal; Nwankwo, Victor; Li, Li; Shervey, Mark M; Glowe, Patricia; Ionita-Laza, Iuliana; Simmerling, Mary; Hripcsak, George; Bakken, Suzanne; Goldstein, David; Kiryluk, Krzysztof; Kenny, Eimear E; Dudley, Joel; Vawdrey, David K; Tatonetti, Nicholas P

    2018-05-15

    Heritability is essential for understanding the biological causes of disease but requires laborious patient recruitment and phenotype ascertainment. Electronic health records (EHRs) passively capture a wide range of clinically relevant data and provide a resource for studying the heritability of traits that are not typically accessible. EHRs contain next-of-kin information collected via patient emergency contact forms, but until now, these data have gone unused in research. We mined emergency contact data at three academic medical centers and identified 7.4 million familial relationships while maintaining patient privacy. Identified relationships were consistent with genetically derived relatedness. We used EHR data to compute heritability estimates for 500 disease phenotypes. Overall, estimates were consistent with the literature and between sites. Inconsistencies were indicative of limitations and opportunities unique to EHR research. These analyses provide a validation of the use of EHRs for genetics and disease research. Copyright © 2018 Elsevier Inc. All rights reserved.

  6. Corticomuscular coherence during hand gripping with DBS and medication in PD patients

    DEFF Research Database (Denmark)

    Sridharan, Kousik Sarathy; Højlund, Andreas; Johnsen, Erik Lisbjerg

    Deep brain stimulation (DBS) effectively alleviates the motor symptoms in Parkinson’s disease (PD) although its effect mechanism is still unclear. CMC is reduced in PD patients but restorable with medication, while DBS variably affects CMC in advanced PD patients. We recorded magnetoencephalography...... (MEG) from six PD patients performing hand gripping during DBS ON and medicated (levodopa, MED ON) conditions and from ten age-matched healthy controls. Participants performed isotonic contractions (hand gripping) with their right hand, and electromyography (EMG) was recorded from the extensor...... digitorum communis muscle with a belly-tendon montage. We calculated the mean-squared coherence between MEG and the rectified EMG signals. For each group and condition, we selected the maximum CMC value in the beta range (13-30 Hz) within the average of an a priori selection of nine left sensorimotor...

  7. Using an electronic medical record to improve communication within a prenatal care network.

    Science.gov (United States)

    Bernstein, Peter S; Farinelli, Christine; Merkatz, Irwin R

    2005-03-01

    In 2002, the Institute of Medicine called for the introduction of information technologies in health care settings to improve quality of care. We conducted a review of hospital charts of women who delivered before and after the implementation of an intranet-based computerized prenatal record in an inner-city practice. Our objective was to assess whether the use of this record improved communication among the outpatient office, the ultrasonography unit, and the labor floor. The charts of patients who delivered in August 2002 and August 2003 and received their prenatal care at the Comprehensive Family Care Center at Montefiore Medical Center were analyzed. Data collected included the presence of a copy of the prenatal record in the hospital chart, the date of the last documented prenatal visit, and documentation of any prenatal ultrasonograms performed. Forty-three charts in each group were available for review. The prenatal chart was absent in 16% of the charts of patients from August 2002 compared with only 2% in August 2003 charts (P intranet-based prenatal chart significantly improves communication among providers.

  8. Medication-related problem type and appearance rate in ambulatory hemodialysis patients

    Directory of Open Access Journals (Sweden)

    Drayer Debra K

    2003-12-01

    Full Text Available Abstract Background Hemodialysis (HD patients are at risk for medication-related problems (MRP. The MRP number, type, and appearance rate over time in ambulatory HD patients has not been investigated. Methods Randomly selected HD patients were enrolled to receive monthly pharmaceutical care visits. At each visit, MRP were identified through review of the patient chart, electronic medical record, patient interview, and communications with other healthcare disciplines. All MRP were categorized by type and medication class. MRP appearance rate was determined as the number of MRP identified per month/number of months in study. The number of MRP per patient-drug exposures were determined using: {[(number of patients × (mean number of medications]/(number of months of study} /number of MRP identified. Results were expressed as mean ± standard deviation or percentages. Results Patients were 62.6 ± 15.9 years old, had 6.4 ± 2.0 comorbid conditions, were taking 12.5 ± 4.2 medications, and 15.7 ± 7.2 doses per day at baseline. Medication-dosing problems (33.5%, adverse drug reactions (20.7%, and an indication that was not currently being treated (13.5% were the most common MRP. 5,373 medication orders were reviewed and a MRP was identified every 15.2 medication exposures. Overall MRP appearance rate was 0.68 ± 0.46 per patient per month. Conclusion MRP continue to occur at a high rate in ambulatory HD patients. Healthcare providers taking care of HD patients should be aware of this problem and efforts to avoid or resolve MRP should be undertaken at all HD clinics.

  9. Discordant Documentation of Obesity Body Mass Index and Obesity Diagnosis in Electronic Medical Records

    Directory of Open Access Journals (Sweden)

    Jennifer T. Fink

    2014-11-01

    Full Text Available Purpose: This study examined concordance between presence of obesity body mass index (BMI, defined as BMI ≥ 30, in the patient’s electronic medical record (EMR and a documented diagnosis of obesity. Methods: We conducted a retrospective review of the EMR in a large health care system for a 1-year period (2012. A total of 397,313 patients met the study criteria of having at least one physician visit, being at least 18 years of age, and not being pregnant. Of those, 158,327 (40% had a recorded BMI ≥ 30. We examined the EMR of these obese patients to determine whether a diagnosis of obesity was recorded, and whether demographics or comorbid diagnoses impacted the likelihood of a recorded obesity diagnosis. Results: Obesity appeared on the EMR problem list for only 35% of patients with BMI ≥ 30. Obesity diagnosis was documented more frequently in women, middle-aged patients and blacks. The presence of some comorbidities (e.g. sleep apnea, hypertension, diabetes led to significantly more frequent diagnosis of obesity. There was a significant positive association between the number of comorbid diagnoses per patient and an obesity diagnosis appearing on the problem list. Conclusions: Obesity remains underrecorded in the EMR problem list despite the presence of obesity BMI in the EMR. Patient demographics and comorbidities should be considered when identifying best practices for weight management. New practices should be patient-centered and consider cultural context as well as the social and physical resources available to patients – all crucial for enacting systems change in a true accountable care environment.

  10. Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study.

    Science.gov (United States)

    Woods, Susan S; Schwartz, Erin; Tuepker, Anais; Press, Nancy A; Nazi, Kim M; Turvey, Carolyn L; Nichol, W Paul

    2013-03-27

    Full sharing of the electronic health record with patients has been identified as an important opportunity to engage patients in their health and health care. The My HealtheVet Pilot, the initial personal health record of the US Department of Veterans Affairs, allowed patients and their delegates to view and download content in their electronic health record, including clinical notes, laboratory tests, and imaging reports. A qualitative study with purposeful sampling sought to examine patients' views and experiences with reading their health records, including their clinical notes, online. Five focus group sessions were conducted with patients and family members who enrolled in the My HealtheVet Pilot at the Portland Veterans Administration Medical Center, Oregon. A total of 30 patients enrolled in the My HealtheVet Pilot, and 6 family members who had accessed and viewed their electronic health records participated in the sessions. Four themes characterized patient experiences with reading the full complement of their health information. Patients felt that seeing their records positively affected communication with providers and the health system, enhanced knowledge of their health and improved self-care, and allowed for greater participation in the quality of their care such as follow-up of abnormal test results or decision-making on when to seek care. While some patients felt that seeing previously undisclosed information, derogatory language, or inconsistencies in their notes caused challenges, they overwhelmingly felt that having more, rather than less, of their health record information provided benefits. Patients and their delegates had predominantly positive experiences with health record transparency and the open sharing of notes and test results. Viewing their records appears to empower patients and enhance their contributions to care, calling into question common provider concerns about the effect of full record access on patient well-being. While shared

  11. Jaundice in primary care: a cohort study of adults aged >45 years using electronic medical records.

    Science.gov (United States)

    Taylor, Anna; Stapley, Sally; Hamilton, William

    2012-08-01

    Jaundice is a rare but important symptom of malignant and benign conditions. When patients present in primary care, understanding the relative likelihood of different disease processes can help GPs to investigate and refer patients appropriately. To identify and quantify the various causes of jaundice in adults presenting in primary care. Historical cohort study using electronic primary care records. UK General Practice Research Database. Participants (186 814 men and women) aged >45 years with clinical events recorded in primary care records between 1 January 2005 and 31 December 2007. Data were searched for episodes of jaundice and explanatory diagnoses identified within the subsequent 12 months. If no diagnosis was found, the patient's preceding medical record was searched for relevant chronic diseases. From the full cohort, 277 patients had at least one record of jaundice between 1 January 2005 and 31 December 2006. Ninety-two (33%) were found to have bile duct stones; 74 (27%) had an explanatory cancer [pancreatic cancer 34 (12%), cholangiocarcinoma 13 (5%) and other diagnosed primary malignancy 27 (10%)]. Liver disease attributed to excess alcohol explained 26 (9%) and other diagnoses were identified in 24 (9%). Sixty-one (22%) had no diagnosis related to jaundice recorded. Although the most common cause of jaundice is bile duct stones, cancers are present in over a quarter of patients with jaundice in this study, demonstrating the importance of urgent investigation into the underlying cause.

  12. Patient-provider communication about medication use at the community pharmacy counter.

    Science.gov (United States)

    van Dijk, Marloes; Blom, Lyda; Koopman, Laura; Philbert, Daphne; Koster, Ellen; Bouvy, Marcel; van Dijk, Liset

    2016-02-01

    The objectives of this study were to, first, describe the information exchanged between pharmacy staff and patients about prescribed medication at the community pharmacy counter, and second, to investigate to what extent this met professional medication counselling guidelines. Pharmaceutical encounters were videotaped in four community pharmacies in the Netherlands. Patients were included if they collected a prescription for their own use. An observation protocol, including the MEDICODE checklist, was used to analyse the video recordings. A distinction was made between first and repeat prescriptions. One hundred fifty-three encounters were videotaped. When dispensing first prescriptions, pharmacy staff provided most information on instructions how to use the medication (83.3%), form of the medication (71.4%) and treatment duration (42.9%). Topics for repeat prescriptions (such as the effects of the medication and the incidence of observed adverse effects) were rarely discussed. Pharmacy staff rarely encouraged patients to ask questions. Pharmacy staff members provided little medication-related information at the counter, especially for repeat prescriptions, did not encourage active patient participation, and thereby did not adhere to the guidelines of their professional organisation. Further research is needed to understand the reasons for this. © 2015 Royal Pharmaceutical Society.

  13. Taiwan's perspective on electronic medical records' security and privacy protection: lessons learned from HIPAA.

    Science.gov (United States)

    Yang, Che-Ming; Lin, Herng-Ching; Chang, Polun; Jian, Wen-Shan

    2006-06-01

    The protection of patients' health information is a very important concern in the information age. The purpose of this study is to ascertain what constitutes an effective legal framework in protecting both the security and privacy of health information, especially electronic medical records. All sorts of bills regarding electronic medical data protection have been proposed around the world including Health Insurance Portability and Accountability Act (HIPAA) of the U.S. The trend of a centralized bill that focuses on managing computerized health information is the part that needs our further attention. Under the sponsor of Taiwan's Department of Health (DOH), our expert panel drafted the "Medical Information Security and Privacy Protection Guidelines", which identifies nine principles and entails 12 articles, in the hope that medical organizations will have an effective reference in how to manage their medical information in a confidential and secured fashion especially in electronic transactions.

  14. An inventory of publications on electronic medical records revisited.

    Science.gov (United States)

    Moorman, P W; Schuemie, M J; van der Lei, J

    2009-01-01

    In this short review we provide an update of our earlier inventories of publications indexed in MedLine with the MeSH term 'Medical Records Systems, Computerized'. We retrieved and analyzed all references to English articles published before January 1, 2008, and indexed in PubMed with the MeSH term 'Medical Records Systems, Computerized'. We retrieved a total of 11,924 publications, of which 3937 (33%) appeared in a journal with an impact factor. Since 2002 the number of yearly publications, and the number of journals in which those publications appeared, increased. A cluster analysis revealed three clusters: an organizational issues cluster, a technically oriented cluster and a cluster about order-entry and research. Although our previous inventory in 2003 suggested a constant yearly production of publications on electronic medical records since 1998, the current inventory shows another rise in production since 2002. In addition, many new journals and countries have shown interest during the last five years. In the last 15 years, interest in organizational issues remained fairly constant, order entry and research with systems gained attention, while interest in technical issues relatively decreased.

  15. Clinical Assistant Diagnosis for Electronic Medical Record Based on Convolutional Neural Network.

    Science.gov (United States)

    Yang, Zhongliang; Huang, Yongfeng; Jiang, Yiran; Sun, Yuxi; Zhang, Yu-Jin; Luo, Pengcheng

    2018-04-20

    Automatically extracting useful information from electronic medical records along with conducting disease diagnoses is a promising task for both clinical decision support(CDS) and neural language processing(NLP). Most of the existing systems are based on artificially constructed knowledge bases, and then auxiliary diagnosis is done by rule matching. In this study, we present a clinical intelligent decision approach based on Convolutional Neural Networks(CNN), which can automatically extract high-level semantic information of electronic medical records and then perform automatic diagnosis without artificial construction of rules or knowledge bases. We use collected 18,590 copies of the real-world clinical electronic medical records to train and test the proposed model. Experimental results show that the proposed model can achieve 98.67% accuracy and 96.02% recall, which strongly supports that using convolutional neural network to automatically learn high-level semantic features of electronic medical records and then conduct assist diagnosis is feasible and effective.

  16. [Cooperation with the electronic medical record and accounting system of an actual dose of drug given by a radiology information system].

    Science.gov (United States)

    Yamamoto, Hideo; Yoneda, Tarou; Satou, Shuji; Ishikawa, Toru; Hara, Misako

    2009-12-20

    By input of the actual dose of a drug given into a radiology information system, the system converting with an accounting system into a cost of the drug from the actual dose in the electronic medical record was built. In the drug master, the first unit was set as the cost of the drug, and we set the second unit as the actual dose. The second unit in the radiology information system was received by the accounting system through electronic medical record. In the accounting system, the actual dose was changed into the cost of the drug using the dose of conversion to the first unit. The actual dose was recorded on a radiology information system and electronic medical record. The actual dose was indicated on the accounting system, and the cost for the drug was calculated. About the actual dose of drug, cooperation of the information in a radiology information system and electronic medical record were completed. It was possible to decide the volume of drug from the correct dose of drug at the previous inspection. If it is necessary for the patient to have another treatment of medicine, it is important to know the actual dose of drug given. Moreover, authenticity of electronic medical record based on a statute has also improved.

  17. Web technology for emergency medicine and secure transmission of electronic patient records.

    Science.gov (United States)

    Halamka, J D

    1998-01-01

    The American Heritage dictionary defines the word "web" as "something intricately contrived, especially something that ensnares or entangles." The wealth of medical resources on the World Wide Web is now so extensive, yet disorganized and unmonitored, that such a definition seems fitting. In emergency medicine, for example, a field in which accurate and complete information, including patients' records, is urgently needed, more than 5000 Web pages are available today, whereas fewer than 50 were available in December 1994. Most sites are static Web pages using the Internet to publish textbook material, but new technology is extending the scope of the Internet to include online medical education and secure exchange of clinical information. This article lists some of the best Web sites for use in emergency medicine and then describes a project in which the Web is used for transmission and protection of electronic medical records.

  18. Patient safety and technology-driven medication e A qualitative study on how graduate nursing students navigate through complex medication administration

    DEFF Research Database (Denmark)

    Orbæk, Janne; Gaard, Mette; Fabricius, Pia

    2014-01-01

    ways of educating nursing students in today's medication administration. Aim: To explore nursing students' experiences and competences with the technology-driven medication administration process. Methods: 16 pre-graduate nursing students were included in two focus group interviews which were recorded...... for the technology-driven medication process, nursing students face difficulties in identifying and adopting best practices. The impact of using technology on the frequency, type and severity of medication errors; the technologies implications on nursing professionalism and the nurses ability to secure patient...

  19. Development of Patient Status-Based Dynamic Access System for Medical Information Systems

    Directory of Open Access Journals (Sweden)

    Chang Won Jeong

    2015-06-01

    Full Text Available Recently, the hospital information system environment using IT communication technology and utilization of medical information has been increasing. In the medical field, the medical information system only supports the transfer of patient information to medical staff through an electronic health record, without information about patient status. Hence, it needs a method of real-time monitoring for the patient. Also, in this environment, a secure method in approaching healthcare through various smart devices is required. Therefore, in this paper, in order to classify the status of the patients, we propose a dynamic approach of the medical information system in a hospital information environment using the dynamic access control method. Also, we applied the symmetric method of AES (Advanced Encryption Standard. This was the best encryption algorithm for sending and receiving biological information. We can define usefulness as the dynamic access application service based on the final result of the proposed system. The proposed system is expected to provide a new solution for a convenient medical information system.

  20. 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.

  1. A Retrospective Analysis of Clinical Laboratory Interferences Caused by Frequently Administered Medications in Burn Patients.

    Science.gov (United States)

    Godwin, Zachary; Lima, Kelly; Greenhalgh, David; Palmieri, Tina; Sen, Soman; Tran, Nam K

    2016-01-01

    The goal of this study is to quantify the number of medications administered to burn patients and identify potential drugs interfering with laboratory testing. The authors reviewed the medical records of 12 adult (age ≥ 18 years) burn patients with more than 20% TBSA burns from an existing glucose control database at our institution. Dose, interval, and route of medications administered from admission to discontinuation of intensive insulin therapy were recorded. Interfering drugs were identified based on established clinical chemistry literature. The retrospective cohort of adult burn patients exhibited a mean (SD) age of 37.9 (3.0) years. Mean TBSA burn was 51.3 (9.3)%. Disease severity determined by the average multiple organ dysfunction score was 5.4 (0.2). Mean and median medications administered per day were 42.1 (9.5) and 49 (with a daily range of 0-65), respectively. A total of 666 potential laboratory test interferences caused by medications were identified. There were 261 different effects (eg, increased glucose, decreased potassium). Multiple interferences, 71.0% (475/666), were caused by more than one medication. Investigation of the number of medications administered to a burn patient and delineation of potential laboratory test interferences has not been conducted in burn patients. Given the substantial number of medications administered to burn patients, physicians and laboratory personnel should work together to identify potential interferences and define appropriate countermeasures while enhancing the laboratorians understanding of this unique population. This synergistic partnership can lead to intelligent support tools and potentially autocorrecting instruments.

  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. © The Author 2015. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  3. 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).

  4. Using the Electronic Medical Record to Reduce Unnecessary Ordering of Coagulation Studies for Patients with Chest Pain

    Directory of Open Access Journals (Sweden)

    Jeremiah S. Hinson

    2017-02-01

    Full Text Available Introduction: Our goal was to reduce ordering of coagulation studies in the emergency department (ED that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR. Methods: We used a pre and post quasi-experimental study design to evaluate the impact of an EMRbased intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured via detailed review of randomly sampled encounters during two-month periods before and after intervention. We classified existing orders as clinically indicated or non-value added. Order frequencies were calculated as percentages, and we assessed differences between groups by chi-square analysis. Results: Pre-intervention, 73.8% (76/103 of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76 were non-value added. Post-intervention, 38.5% (40/104 of patients with chest pain had coagulation studies ordered, of which 60% (24/40 were non-value added. There was an absolute reduction of 35.3% (95% confidence interval [CI]: 22.7%, 48.0% in the total ordering of coagulation studies and 26.4% (95% CI: 13.8%, 39.0% in non-value added order placement. Conclusion: Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies. [West J Emerg Med. 2017;18(2267-269.

  5. On standardization of basic datasets of electronic medical records in traditional Chinese medicine.

    Science.gov (United States)

    Zhang, Hong; Ni, Wandong; Li, Jing; Jiang, Youlin; Liu, Kunjing; Ma, Zhaohui

    2017-12-24

    Standardization of electronic medical record, so as to enable resource-sharing and information exchange among medical institutions has become inevitable in view of the ever increasing medical information. The current research is an effort towards the standardization of basic dataset of electronic medical records in traditional Chinese medicine. In this work, an outpatient clinical information model and an inpatient clinical information model are created to adequately depict the diagnosis processes and treatment procedures of traditional Chinese medicine. To be backward compatible with the existing dataset standard created for western medicine, the new standard shall be a superset of the existing standard. Thus, the two models are checked against the existing standard in conjunction with 170,000 medical record cases. If a case cannot be covered by the existing standard due to the particularity of Chinese medicine, then either an existing data element is expanded with some Chinese medicine contents or a new data element is created. Some dataset subsets are also created to group and record Chinese medicine special diagnoses and treatments such as acupuncture. The outcome of this research is a proposal of standardized traditional Chinese medicine medical records datasets. The proposal has been verified successfully in three medical institutions with hundreds of thousands of medical records. A new dataset standard for traditional Chinese medicine is proposed in this paper. The proposed standard, covering traditional Chinese medicine as well as western medicine, is expected to be soon approved by the authority. A widespread adoption of this proposal will enable traditional Chinese medicine hospitals and institutions to easily exchange information and share resources. Copyright © 2017. Published by Elsevier B.V.

  6. Hiding Electronic Patient Record (EPR) in medical images: A high capacity and computationally efficient technique for e-healthcare applications.

    Science.gov (United States)

    Loan, Nazir A; Parah, Shabir A; Sheikh, Javaid A; Akhoon, Jahangir A; Bhat, Ghulam M

    2017-09-01

    A high capacity and semi-reversible data hiding scheme based on Pixel Repetition Method (PRM) and hybrid edge detection for scalable medical images has been proposed in this paper. PRM has been used to scale up the small sized image (seed image) and hybrid edge detection ensures that no important edge information is missed. The scaled up version of seed image has been divided into 2×2 non overlapping blocks. In each block there is one seed pixel whose status decides the number of bits to be embedded in the remaining three pixels of that block. The Electronic Patient Record (EPR)/data have been embedded by using Least Significant and Intermediate Significant Bit Substitution (ISBS). The RC4 encryption has been used to add an additional security layer for embedded EPR/data. The proposed scheme has been tested for various medical and general images and compared with some state of art techniques in the field. The experimental results reveal that the proposed scheme besides being semi-reversible and computationally efficient is capable of handling high payload and as such can be used effectively for electronic healthcare applications. Copyright © 2017. Published by Elsevier Inc.

  7. 77 FR 65564 - Privacy Act of 1974; System of Records

    Science.gov (United States)

    2012-10-29

    ... Medical, Health and Billing Records system is the authoritative source of patients' IHS medical records... authoritative records, nor are they considered part of the IHS Medical, Health and Billing Records system of...

  8. 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.

  9. A Retrospective Medical Records Review of Risk Factors for the Development of Respiratory Tract Secretions (Death Rattle) in the Dying Patient.

    Science.gov (United States)

    Kolb, Hildegard; Snowden, Austyn; Stevens, Elaine; Atherton, Iain

    2018-05-09

    Identification of risk factors predicting the development of death rattle. Respiratory tract secretions, often called death rattle, are among the most common symptoms in dying patients around the world. It is unknown whether death rattle causes distress in patients, but it has been globally reported that distress levels can be high in family members. Although there is a poor evidence base, treatment with antimuscarinic medication is standard practice worldwide and prompt intervention is recognised as crucial for effectiveness. The identification of risk factors for the development of death rattle would allow for targeted interventions. A case ̶ control study was designed to retrospectively review two hundred consecutive medical records of mainly cancer patients who died in a hospice inpatient setting between 2009 - 2011. Fifteen potential risk factors including the original factors weight, smoking, final opioid dose and final Midazolam dose were investigated. Binary logistic regression to identify risk factors for death rattle development. Univariate analysis showed death rattle was significantly associated with final Midazolam doses and final opioid doses, length of dying phase and anticholinergic drug load in the pre-terminal phase. In the final logistic regression model only Midazolam was statistically significant and only at final doses of 20 mg/24hrs or over (OR 3.81 CI 1.41-10.34). Dying patients with a requirement for a high dose of Midazolam have an increased likelihood of developing death rattle. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

  10. Building clinical data groups for electronic medical record in China.

    Science.gov (United States)

    Tu, Haibo; Yu, Yingtao; Yang, Peng; Tang, Xuejun; Hu, Jianping; Rao, Keqin; Pan, Feng; Xu, Yongyong; Liu, Danhong

    2012-04-01

    This article aims at building clinical data groups for Electronic Medical Records (EMR) in China. These data groups can be reused as basic information units in building the medical sheets of Electronic Medical Record Systems (EMRS) and serve as part of its implementation guideline. The results were based on medical sheets, the forms that are used in hospitals, which were collected from hospitals. To categorize the information in these sheets into data groups, we adopted the Health Level 7 Clinical Document Architecture Release 2 Model (HL7 CDA R2 Model). The regulations and legal documents concerning health informatics and related standards in China were implemented. A set of 75 data groups with 452 data elements was created. These data elements were atomic items that comprised the data groups. Medical sheet items contained clinical records information and could be described by standard data elements that exist in current health document protocols. These data groups match different units of the CDA model. Twelve data groups with 87 standardized data elements described EMR headers, and 63 data groups with 405 standardized data elements constituted the body. The later 63 data groups in fact formed the sections of the model. The data groups had two levels. Those at the first level contained both the second level data groups and the standardized data elements. The data groups were basically reusable information units that served as guidelines for building EMRS and that were used to rebuild a medical sheet and serve as templates for the clinical records. As a pilot study of health information standards in China, the development of EMR data groups combined international standards with Chinese national regulations and standards, and this was the most critical part of the research. The original medical sheets from hospitals contain first hand medical information, and some of their items reveal the data types characteristic of the Chinese socialist national health system

  11. From patient care to research: a validation study examining the factors contributing to data quality in a primary care electronic medical record database.

    Science.gov (United States)

    Coleman, Nathan; Halas, Gayle; Peeler, William; Casaclang, Natalie; Williamson, Tyler; Katz, Alan

    2015-02-05

    Electronic Medical Records (EMRs) are increasingly used in the provision of primary care and have been compiled into databases which can be utilized for surveillance, research and informing practice. The primary purpose of these records is for the provision of individual patient care; validation and examination of underlying limitations is crucial for use for research and data quality improvement. This study examines and describes the validity of chronic disease case definition algorithms and factors affecting data quality in a primary care EMR database. A retrospective chart audit of an age stratified random sample was used to validate and examine diagnostic algorithms applied to EMR data from the Manitoba Primary Care Research Network (MaPCReN), part of the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The presence of diabetes, hypertension, depression, osteoarthritis and chronic obstructive pulmonary disease (COPD) was determined by review of the medical record and compared to algorithm identified cases to identify discrepancies and describe the underlying contributing factors. The algorithm for diabetes had high sensitivity, specificity and positive predictive value (PPV) with all scores being over 90%. Specificities of the algorithms were greater than 90% for all conditions except for hypertension at 79.2%. The largest deficits in algorithm performance included poor PPV for COPD at 36.7% and limited sensitivity for COPD, depression and osteoarthritis at 72.0%, 73.3% and 63.2% respectively. Main sources of discrepancy included missing coding, alternative coding, inappropriate diagnosis detection based on medications used for alternate indications, inappropriate exclusion due to comorbidity and loss of data. Comparison to medical chart review shows that at MaPCReN the CPCSSN case finding algorithms are valid with a few limitations. This study provides the basis for the validated data to be utilized for research and informs users of its

  12. Nurses, medical records and the killing of sick persons before, during and after the Nazi regime in Germany.

    Science.gov (United States)

    Foth, Thomas

    2013-06-01

    During the Nazi regime (1933-1945), more than 300,000 psychiatric patients were killed. The well-calculated killing of chronic mentally 'ill' patients was part of a huge biopolitical program of well-established scientific, eugenic standards of the time. Among the medical personnel implicated in these assassinations were nurses, who carried out this program through their everyday practice. However, newer research raises suspicions that psychiatric patients were being assassinated before and after the Nazi regime, which, I hypothesize, implies that the motives for these killings must be investigated within psychiatric practice itself. An investigation of the impact of the interplay between the notes left by nurses and those by psychiatrists illustrates the active role of the psychiatric medical record in the killing of these patients. Using theoretical insights from Michel Foucault and philosopher Giorgio Agamben and analyzing one part of a particularly rich patient file found in the Langenhorn Psychiatric Asylum in the city of Hamburg, I demonstrate the role of the record in both constructing and deconstructing patient subjectivities. De-subjectifying patients condemned them to specific zones in the asylum within which they were reduced to their 'bare life'--a precondition for their physical assassination. © 2012 John Wiley & Sons Ltd.

  13. 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.

  14. Perspectives for medical informatics. Reusing the electronic medical record for clinical research.

    Science.gov (United States)

    Prokosch, H U; Ganslandt, T

    2009-01-01

    Even though today most university hospitals have already implemented commercial hospital information systems and started to build up comprehensive electronic medical records, reuse of such data for data warehousing and research purposes is still very rare. Given this situation, the focus of this paper is to present an overview on exemplary projects, which have already tackled this challenge, reflect on current initiatives within the United States of America and the European Union to establish IT infrastructures for clinical and translational research, and draw attention to new challenges in this area. This paper does not intend to provide a fully comprehensive review on all the issues of clinical routine data reuse. It is based, however, on a presentation of a large variety of historical, but also most recent activities in data warehousing, data retrieval and linking medical informatics with translational research. The article presents an overview of the various international approaches to this issue and illustrates concepts and solutions which have been published, thus giving an impression of activities pursued in this field of medical informatics. Further, problems and open questions, which have also been named in the literature, are presented and three challenges (to establish comprehensive clinical data warehouses, to establish professional IT infrastructure applications supporting clinical trial data capture and to integrate medical record systems and clinical trial databases) related to this area of medical informatics are identified and presented. Translational biomedical research with the aim "to integrate bedside and biology" and to bridge the gap between clinical care and medical research today and in the years to come, provides a large and interesting field for medical informatics researchers. Especially the need for integrating clinical research projects with data repositories built up during documentation of routine clinical care, today still leaves

  15. “Nothing About Me Without Me”: An Interpretative Review of Patient Accessible Electronic Health Records

    Science.gov (United States)

    Callahan, Ryan; Sevdalis, Nick; Mayer, Erik K; Darzi, Ara

    2015-01-01

    Background Patient accessible electronic health records (PAEHRs) enable patients to access and manage personal clinical information that is made available to them by their health care providers (HCPs). It is thought that the shared management nature of medical record access improves patient outcomes and improves patient satisfaction. However, recent reviews have found that this is not the case. Furthermore, little research has focused on PAEHRs from the HCP viewpoint. HCPs include physicians, nurses, and service providers. Objective We provide a systematic review of reviews of the impact of giving patients record access from both a patient and HCP point of view. The review covers a broad range of outcome measures, including patient safety, patient satisfaction, privacy and security, self-efficacy, and health outcome. Methods A systematic search was conducted using Web of Science to identify review articles on the impact of PAEHRs. Our search was limited to English-language reviews published between January 2002 and November 2014. A total of 73 citations were retrieved from a series of Boolean search terms including “review*” with “patient access to records”. These reviews went through a novel scoring system analysis whereby we calculated how many positive outcomes were reported per every outcome measure investigated. This provided a way to quantify the impact of PAEHRs. Results Ten reviews covering chronic patients (eg, diabetes and hypertension) and primary care patients, as well as HCPs were found but eight were included for the analysis of outcome measures. We found mixed outcomes across both patient and HCP groups, with approximately half of the reviews showing positive changes with record access. Patients believe that record access increases their perception of control; however, outcome measures thought to create psychological concerns (such as patient anxiety as a result of seeing their medical record) are still unanswered. Nurses are more likely than

  16. 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.

  17. Medical record automation at the Los Alamos Scientific Laboratory

    International Nuclear Information System (INIS)

    Hogle, G.O.; Grier, R.S.

    1979-01-01

    With the increase in population at the Los Alamos Scientific Laboratory and the growing concern over employee health, especially concerning the effects of the work environment, the Occupational Medicine Group decided to automate its medical record keeping system to meet these growing demands. With this computer system came not only the ability for long-term study of the work environment verses employee health, but other benefits such as more comprehensive records, increased legibility, reduced physician time, and better records management

  18. From planning to realisation of an electronic patient record.

    Science.gov (United States)

    Krämer, T; Rapp, R; Krämer, K-L

    1999-03-01

    The high complex requirements on information and information flow in todays hospitals can only be accomplished by the use of modern Information Systems (IS). In order to achieve this, the Stiftung Orthopädische Universitätsklinik has carried out first the Project "Strategic Informations System Planning" in 1993. Then realizing the neccessary infrastructure (network; client-server) from 1993 to 1997, and finally started the introduction of modern IS (SAP R/3 and IXOS-Archive) in the clinical area. One of the approved goal was the replacement of the paper medical record by an up-to-date electronical medical record. In this article the following three topics will be discussed: the difference between the up-to-date electronical medical record and the electronically archived finished cases, steps performed by our clinic to realize the up-to-date electronical medical record and the problems occured during this process.

  19. [From planning to realization of an electronic patient record].

    Science.gov (United States)

    Krämer, T; Rapp, R; Krämer, K L

    1999-03-01

    The high complex requirements on information and information flow in todays hospitals can only be accomplished by the use of modern Information Systems (IS). In order to achieve this, the Stiftung Orthopädische Universitätsklinik has carried out first the Project "Strategic Informations System Planning" in 1993. Then realizing the necessary infrastructure (network; client-server) from 1993 to 1997, and finally started the introduction of modern IS (SAP R/3 and IXOS-Archive) in the clinical area. One of the approved goal was the replacement of the paper medical record by an up-to-date electronical medical record. In this article the following three topics will be discussed: the difference between the up-to-date electronical medical record and the electronically archived finished cases, steps performed by our clinic to realize the up-to-date electronical medical record and the problems occurred during this process.

  20. Permanent record. Electronic records aid in the aftermath of Joplin tornado.

    Science.gov (United States)

    Russell, Matthew

    2011-09-01

    When a tornado struck St. John's Regional Medical Center in May 2011, its patient records were stored in a newly launched electronic health record system, helping prevent a bad situation from being worse.

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

    Science.gov (United States)

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

    2017-09-01

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

  2. 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

  3. Evaluation of medical record quality and communication skills among pediatric interns after standardized parent training history-taking in China.

    Science.gov (United States)

    Yu, Mu Xue; Jiang, Xiao Yun; Li, Yi Juan; Shen, Zhen Yu; Zhuang, Si Qi; Gu, Yu Fen

    2018-02-01

    The effect of using standardized parent training history-taking on the quality of medical records and communication skills among pediatric interns was determined. Fifth-year interns who were undertaking a pediatric clinical practice rotation were randomized to intervention and control groups. All of the pediatric interns received history-taking training by lecture and bedside teaching. The pediatric interns in the intervention group also received standardized parent history-taking training. The following two outcome measures were used: the scores of medical records, which were written by the pediatric interns after history-taking from real parents of pediatric patients; and the communication assessment tool (CAT) assessed by real parents. The general information, history of present illness (HPI), past medical history, personal history, family history, diagnosis, diagnostic analysis, and differential diagnosis scores in the intervention group were significantly higher than the control group (p history-taking is effective in improving the quality of medical records by pediatric interns. Standardized parent training history-taking is a superior teaching tool for clinical reasoning ability, as well as communication skills in clinical pediatric practice.

  4. Patient safety and technology-driven medication - A qualitative study on how graduate nursing students navigate through complex medication administration.

    Science.gov (United States)

    Orbæk, Janne; Gaard, Mette; Fabricius, Pia; Lefevre, Rikke S; Møller, Tom

    2015-05-01

    The technology-driven medication process is complex, involving advanced technologies, patient participation and increased safety measures. Medication administration errors are frequently reported, with nurses implicated in 26-38% of in-hospital cases. This points to the need for new ways of educating nursing students in today's medication administration. To explore nursing students' experiences and competences with the technology-driven medication administration process. 16 pre-graduate nursing students were included in two focus group interviews which were recorded, transcribed and analyzed using the systematic horizontal phenomenological-hermeneutic template methodology. The interviews uncovered that understanding the technologies; professionalism and patient safety are three crucial elements in the medication process. The students expressed positivity and confidence in using technology, but were fearful of committing serious medication errors. From the nursing students' perspective, experienced nurses deviate from existing guidelines, leaving them feeling isolated in practical learning situations. Having an unclear nursing role model for the technology-driven medication process, nursing students face difficulties in identifying and adopting best practices. The impact of using technology on the frequency, type and severity of medication errors; the technologies implications on nursing professionalism and the nurses ability to secure patient adherence to the medication process, still remains to be studied. Copyright © 2014 Elsevier Ltd. All rights reserved.

  5. Trained student pharmacists’ telephonic collection of patient medication information: Evaluation of a structured interview tool

    Science.gov (United States)

    Margolis, Amanda R.; Martin, Beth A.; Mott, David A.

    2016-01-01

    Objective To determine the feasibility and fidelity of student pharmacists collecting patient medication list information using a structured interview tool and the accuracy of documenting the information. The medication lists were used by a community pharmacist to provide a targeted medication therapy management (MTM) intervention. Design Descriptive analysis of patient medication lists collected via telephone interviews. Participants 10 trained student pharmacists collected the medication lists. Intervention Trained student pharmacists conducted audio-recorded telephone interviews with 80 English-speaking community dwelling older adults using a structured interview tool to collect and document medication lists. Main outcome measures Feasibility was measured using the number of completed interviews, the time student pharmacists took to collect the information, and pharmacist feedback. Fidelity to the interview tool was measured by assessing student pharmacists’ adherence to asking all scripted questions and probes. Accuracy was measured by comparing the audio recorded interviews to the medication list information documented in an electronic medical record. Results On average it took student pharmacists 26.7 minutes to collect the medication lists. The community pharmacist said the medication lists were complete and that having the medication lists saved time and allowed him to focus on assessment, recommendations, and education during the targeted MTM session. Fidelity was high with an overall proportion of asked scripted probes of 83.75% (95%CI: 80.62–86.88%). Accuracy was also high for both prescription (95.1%, 95%CI: 94.3–95.8%) and non-prescription (90.5%, 95%CI: 89.4–91.4%) medications. Conclusion Trained student pharmacists were able to use an interview tool to collect and document medication lists with a high degree of fidelity and accuracy. This study suggests that student pharmacists or trained technicians may be able to collect patient medication

  6. Trained student pharmacists' telephonic collection of patient medication information: Evaluation of a structured interview tool.

    Science.gov (United States)

    Margolis, Amanda R; Martin, Beth A; Mott, David A

    2016-01-01

    To determine the feasibility and fidelity of student pharmacists collecting patient medication list information using a structured interview tool and the accuracy of documenting the information. The medication lists were used by a community pharmacist to provide a targeted medication therapy management (MTM) intervention. Descriptive analysis of patient medication lists collected with telephone interviews. Ten trained student pharmacists collected the medication lists. Trained student pharmacists conducted audio-recorded telephone interviews with 80 English-speaking, community-dwelling older adults using a structured interview tool to collect and document medication lists. Feasibility was measured using the number of completed interviews, the time student pharmacists took to collect the information, and pharmacist feedback. Fidelity to the interview tool was measured by assessing student pharmacists' adherence to asking all scripted questions and probes. Accuracy was measured by comparing the audio-recorded interviews to the medication list information documented in an electronic medical record. On average, it took student pharmacists 26.7 minutes to collect the medication lists. The community pharmacist said the medication lists were complete and that having the medication lists saved time and allowed him to focus on assessment, recommendations, and education during the targeted MTM session. Fidelity was high, with an overall proportion of asked scripted probes of 83.75% (95% confidence interval [CI], 80.62-86.88%). Accuracy was also high for both prescription (95.1%; 95% CI, 94.3-95.8%) and nonprescription (90.5%; 95% CI, 89.4-91.4%) medications. Trained student pharmacists were able to use an interview tool to collect and document medication lists with a high degree of fidelity and accuracy. This study suggests that student pharmacists or trained technicians may be able to collect patient medication lists to facilitate MTM sessions in the community pharmacy

  7. Privacy, confidentiality, and electronic medical records.

    OpenAIRE

    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 gui...

  8. The design and implementation of online medical record system ...

    African Journals Online (AJOL)

    The design and implementation of online medical record system (OMRS) ... PROMOTING ACCESS TO AFRICAN RESEARCH. AFRICAN JOURNALS ONLINE (AJOL) ... International Journal of Natural and Applied Sciences. Journal Home ...

  9. Progress in electronic medical record adoption in Canada.

    Science.gov (United States)

    2015-12-01

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

  10. Management evaluation about introduction of electric medical record in the national hospital organization.

    Science.gov (United States)

    Nakagawa, Yoshiaki; Tomita, Naoko; Irisa, Kaoru; Yoshihara, Hiroyuki; Nakagawa, Yoshinobu

    2013-01-01

    Introduction of Electronic Medical Record (EMR) into a hospital was started from 1999 in Japan. Then, most of all EMR company said that EMR improved efficacy of the management of the hospital. National Hospital Organization (NHO) has been promoting the project and introduced EMR since 2004. NHO has 143 hospitals, 51 hospitals offer acute-phase medical care services, the other 92 hospitals offer medical services mainly for chronic patients. We conducted three kinds of investigations, questionnaire survey, checking the homepage information of the hospitals and analyzing the financial statements of each NHO hospital. In this financial analysis, we applied new indicators which have been developed based on personnel costs. In 2011, there are 44 hospitals which have introduced EMR. In our result, the hospital with EMR performed more investment of equipment/capital than personnel expenses. So, there is no advantage of EMR on the financial efficacy.

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

    Science.gov (United States)

    2010-01-01

    ... pesticide required to be maintained under § 110.3 is necessary to provide medical treatment or first aid to... care professional, to be a medical emergency, the record information of the restricted use pesticide, relating to the medical emergency, shall be provided immediately. (b)(1) The attending licensed health care...

  12. Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system.

    Science.gov (United States)

    Sardaneh, Arwa A; Burke, Rosemary; Ritchie, Angus; McLachlan, Andrew J; Lehnbom, Elin C

    2017-05-01

    To investigate the impact of the introduction of an electronic medication management system on the proportion of patients with a recorded medication reconciliation on admission, the time from admission to when medication reconciliation was performed, and the characteristics of patients receiving this intervention pre-and post-implementation. An electronic medication management system was implemented in an Australian hospital from May to July 2015. A retrospective observational study was conducted in three wards across two phases; pre- (August 2014) and post- (August 2015) implementation. The study sample included every second patient admitted to these wards. A total of 370 patients were included, 179 pre- and 191 post-implementation. The proportion of recorded admission medication reconciliation significantly increased post-implementation in all study wards; coronary care unit (40 vs 68%, p=0.004), gastroenterology ward (39 vs 59%, p=0.015), and the neurology ward (19 vs 45%, p=0.002). The proportion of patients with recorded medication reconciliation within 24h of weekday admissions, or 48-72h of weekend admissions, increased from 47% pre- to 84% post-implementation. Admission medication reconciliation was recorded within a median of 1.0day for weekday admissions pre- and post-implementation (IQR 1.1 vs 0.2, respectively), and 3.5days (IQR 2.0) pre-implementation vs 1.5days (IQR 2.0) post-implementation for weekend admissions. Overall, across both phases pre-and post-implementation, admission medication reconciliation was recorded for patients who were significantly older (median 77 and 71 years, p<0.001), had a higher number of preadmission medications (median 6.5 and 5.0 medicines, p=0.001), and had a longer hospital stay (median 6.5 and 5.1days, p=0.003). A significantly higher proportion of patients with recorded medication reconciliation in the pre-implementation phase experienced polypharmacy (61%, p=0.002), hyperpolypharmacy (15%, p=0.001), and used a high

  13. Digital Sport Medical Record: Sigh or a blessing?

    NARCIS (Netherlands)

    Stege, J.P.; Fleuren, M.A.H.; van der Knaap, E.T.W.; Stubbe, J.H.

    2013-01-01

    Since 2004, there have been several initiatives regarding the development of a digital Sport Medical Record (SMD). Interviews with the Netherlands Association of Sports Medicine (VSG) show that there are particular problems with commissioning of the digital SMD. During spring 2012, two focus group

  14. 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.

  15. Clinical Databases Originating in Electronic Patient Records

    Czech Academy of Sciences Publication Activity Database

    Zvárová, Jana

    2002-01-01

    Roč. 22, č. 1 (2002), s. 43-60 ISSN 0208-5216 R&D Projects: GA MŠk LN00B107 Keywords : medical informatics * tekemedicine * electronic health record * electronic medical guidelines * decision-support systems * cardiology Subject RIV: BD - Theory of Information

  16. Data-driven approach for assessing utility of medical tests using electronic medical records.

    Science.gov (United States)

    Skrøvseth, Stein Olav; Augestad, Knut Magne; Ebadollahi, Shahram

    2015-02-01

    To precisely define the utility of tests in a clinical pathway through data-driven analysis of the electronic medical record (EMR). The information content was defined in terms of the entropy of the expected value of the test related to a given outcome. A kernel density classifier was used to estimate the necessary distributions. To validate the method, we used data from the EMR of the gastrointestinal department at a university hospital. Blood tests from patients undergoing surgery for gastrointestinal surgery were analyzed with respect to second surgery within 30 days of the index surgery. The information content is clearly reflected in the patient pathway for certain combinations of tests and outcomes. C-reactive protein tests coupled to anastomosis leakage, a severe complication show a clear pattern of information gain through the patient trajectory, where the greatest gain from the test is 3-4 days post index surgery. We have defined the information content in a data-driven and information theoretic way such that the utility of a test can be precisely defined. The results reflect clinical knowledge. In the case we used the tests carry little negative impact. The general approach can be expanded to cases that carry a substantial negative impact, such as in certain radiological techniques. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

  17. Evaluating the Impact of Sample Medication on Subsequent Patient Adherence.

    Science.gov (United States)

    Pringle, Janice L; Aldridge, Arnie; Kearney, Shannon M; Grasso, Kim; Radack, John; Hogue, Susan; Manolis, Chronis

    2016-11-01

    Medication nonadherence is problematic throughout health care practice. Patient nonadherence is a result of several factors, such as financial issues, confusion about the medication, or concerns about possible side effects. Efforts to improve adherence have been implemented, but new strategies are needed to ensure that patients fill their medication prescriptions and adhere to their prescribed use. To investigate whether providing patients with a free 30-day supply of medication at the point of care via a dispensing kiosk-a secure, computerized cabinet placed in the prescriber's office-that provides sample medication and educational materials had a measurable impact on adherence and health care cost. The study sample consisted of patients drawn from the electronic health records of a large health care provider who were prescribed medications to treat diabetes, hypertension, and dyslipidemia. The comparison groups included a treatment group of patients who each received a 30-day generic sample of medication and a control group of patients who did not receive a sample. The study outcome was primary medication non-adherence (PMN), defined as whether a patient filled a prescription within 90, 180, or 365 days of prescribing. Only patients receiving a prescription for the first time were considered; patients on a medication before receipt of the sample were dropped. Postprescription medication adherence (PPMA), measured as proportion of days covered (PDC) and proportion of days covered ≥ 80% (PDC80), was also examined. Propensity score methods and multivariate regression models were used to examine the outcomes and group differences. Costs to the patient before and after the prescription were also analyzed. Key informant interviews were conducted with physicians, and qualitative analyses were performed. Patients who received a 30-day generic medication sample had a higher probability of filling a first prescription within 90 days (72.2% for treatment patients vs. 37

  18. 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.

  19. Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review

    Directory of Open Access Journals (Sweden)

    Olson Matthew D

    2012-08-01

    Full Text Available Abstract Background Medical records that do not accurately reflect the patient’s current medication list are an open invitation to errors and may compromise patient safety. Methods This cross-sectional study compares primary care provider (PCP medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the association of congruence with demographic, clinical, and practice characteristics. Medication list congruence was measured as agreement of pharmacy claims with the entire PCP chart, including current medication list, visit notes, and correspondence sections. Results Congruence between pharmacy claims and the PCP chart was 65%. Congruence was associated with large chronic disease burden, frequent PCP visits, group practice, and patient age ≥45 years. Conclusion Agreement of medication lists between the PCP chart and pharmacy records is low. Medication documentation was more accurate among patients who have more chronic conditions, those who have frequent PCP visits, those whose practice has multiple providers, and those at least 45 years of age. Improved congruence among patients with multiple chronic conditions and in group practices may reflect more frequent visits and reviews by providers.

  20. Assessing explicit error reporting in the narrative electronic medical record using keyword searching.

    Science.gov (United States)

    Cao, Hui; Stetson, Peter; Hripcsak, George

    2003-01-01

    Many types of medical errors occur in and outside of hospitals, some of which have very serious consequences and increase cost. Identifying errors is a critical step for managing and preventing them. In this study, we assessed the explicit reporting of medical errors in the electronic record. We used five search terms "mistake," "error," "incorrect," "inadvertent," and "iatrogenic" to survey several sets of narrative reports including discharge summaries, sign-out notes, and outpatient notes from 1991 to 2000. We manually reviewed all the positive cases and identified them based on the reporting of physicians. We identified 222 explicitly reported medical errors. The positive predictive value varied with different keywords. In general, the positive predictive value for each keyword was low, ranging from 3.4 to 24.4%. Therapeutic-related errors were the most common reported errors and these reported therapeutic-related errors were mainly medication errors. Keyword searches combined with manual review indicated some medical errors that were reported in medical records. It had a low sensitivity and a moderate positive predictive value, which varied by search term. Physicians were most likely to record errors in the Hospital Course and History of Present Illness sections of discharge summaries. The reported errors in medical records covered a broad range and were related to several types of care providers as well as non-health care professionals.

  1. 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

  2. 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

  3. Personal health records in the preclinical medical curriculum: modeling student responses in a simple educational environment utilizing Google Health

    Directory of Open Access Journals (Sweden)

    Karamanlis Dimokratis A

    2012-09-01

    Full Text Available Abstract Background Various problems concerning the introduction of personal health records in everyday healthcare practice are reported to be associated with physicians’ unfamiliarity with systematic means of electronically collecting health information about their patients (e.g. electronic health records - EHRs. Such barriers may further prevent the role physicians have in their patient encounters and the influence they can have in accelerating and diffusing personal health records (PHRs to the patient community. One way to address these problems is through medical education on PHRs in the context of EHR activities within the undergraduate medical curriculum and the medical informatics courses in specific. In this paper, the development of an educational PHR activity based on Google Health is reported. Moreover, student responses on PHR’s use and utility are collected and presented. The collected responses are then modelled to relate the satisfaction level of students in such a setting to the estimation about their attitude towards PHRs in the future. Methods The study was conducted by designing an educational scenario about PHRs, which consisted of student instruction on Google Health as a model PHR and followed the guidelines of a protocol that was constructed for this purpose. This scenario was applied to a sample of 338 first-year undergraduate medical students. A questionnaire was distributed to each one of them in order to obtain Likert-like scale data on the sample’s response with respect to the PHR that was used; the data were then further analysed descriptively and in terms of a regression analysis to model hypothesised correlations. Results Students displayed, in general, satisfaction about the core PHR functions they used and they were optimistic about using them in the future, as they evaluated quite high up the level of their utility. The aspect they valued most in the PHR was its main role as a record-keeping tool, while

  4. Web tools for effective retrieval, visualization, and evaluation of cardiology medical images and records

    Science.gov (United States)

    Masseroli, Marco; Pinciroli, Francesco

    2000-12-01

    To provide easy retrieval, integration and evaluation of multimodal cardiology images and data in a web browser environment, distributed application technologies and java programming were used to implement a client-server architecture based on software agents. The server side manages secure connections and queries to heterogeneous remote databases and file systems containing patient personal and clinical data. The client side is a Java applet running in a web browser and providing a friendly medical user interface to perform queries on patient and medical test dat and integrate and visualize properly the various query results. A set of tools based on Java Advanced Imaging API enables to process and analyze the retrieved cardiology images, and quantify their features in different regions of interest. The platform-independence Java technology makes the developed prototype easy to be managed in a centralized form and provided in each site where an intranet or internet connection can be located. Giving the healthcare providers effective tools for querying, visualizing and evaluating comprehensively cardiology medical images and records in all locations where they can need them- i.e. emergency, operating theaters, ward, or even outpatient clinics- the developed prototype represents an important aid in providing more efficient diagnoses and medical treatments.

  5. A Shared Decision-Making System for Diabetes Medication Choice Utilizing Electronic Health Record Data.

    Science.gov (United States)

    Wang, Yu; Li, Peng-Fei; Tian, Yu; Ren, Jing-Jing; Li, Jing-Song

    2017-09-01

    The use of a shared decision-making (SDM) process in antihyperglycemic medication strategy decisions is necessary due to the complexity of the conditions of diabetes patients. Knowledge of guidelines is used as decision aids in clinical situations, and during this process, no patient health conditions are considered. In this paper, we propose an SDM system framework for type-2 diabetes mellitus (T2DM) patients that not only contains knowledge abstracted from guidelines but also employs a multilabel classification model that uses class-imbalanced electronic health record (EHR) data and that aims to provide a recommended list of available antihyperglycemic medications to help physicians and patients have an SDM conversation. The use of EHR data to serve as a decision-support component in decision aids helps physicians and patients to reach a more intuitive understanding of current health conditions and allows the tailoring of the available knowledge to each patient, leading to a more effective SDM. Real-world data from 2542 T2DM inpatient EHRs were substituted by 77 features and eight output labels, i.e., eight antihyperglycemic medications, and these data were utilized to build and validate the recommendation model. The multilabel recommendation model exhibited stable performance in every single-label classification and showed the ability to predict minority positive cases in which the average recall value of the eight classes was 0.9898. As a whole multilabel classifier, the recommendation model demonstrated outstanding performance, with scores of 0.0941 for Hamming Loss, 0.7611 for Accuracy exam , 0.9664 for Recall exam , and 0.8269 for F exam .

  6. Identifying patients with hypertension: a case for auditing electronic health record data.

    Science.gov (United States)

    Baus, Adam; Hendryx, Michael; Pollard, Cecil

    2012-01-01

    Problems in the structure, consistency, and completeness of electronic health record data are barriers to outcomes research, quality improvement, and practice redesign. This nonexperimental retrospective study examines the utility of importing de-identified electronic health record data into an external system to identify patients with and at risk for essential hypertension. We find a statistically significant increase in cases based on combined use of diagnostic and free-text coding (mean = 1,256.1, 95% CI 1,232.3-1,279.7) compared to diagnostic coding alone (mean = 1,174.5, 95% CI 1,150.5-1,198.3). While it is not surprising that significantly more patients are identified when broadening search criteria, the implications are critical for quality of care, the movement toward the National Committee for Quality Assurance's Patient-Centered Medical Home program, and meaningful use of electronic health records. Further, we find a statistically significant increase in potential cases based on the last two or more blood pressure readings greater than or equal to 140/90 mm Hg (mean = 1,353.9, 95% CI 1,329.9-1,377.9).

  7. Family history record and hereditary cancer risk perception according to National Cancer Institute criteria in a Spanish medical oncology service: a retrospective study.

    Science.gov (United States)

    Márquez-Rodas, Iván; López-Trabada, Daniel; Rupérez Blanco, Ana Belén; Custodio Cabello, Sara; Peligros Gómez, María Isabel; Orera Clemente, María; Calvo, Felipe A; Martín, Miguel

    2012-01-01

    Identification of patients at risk of hereditary cancer is an essential component of oncology practice, since it enables clinicians to offer early detection and prevention programs. However, the large number of hereditary syndromes makes it difficult to take them all into account in daily practice. Consequently, the National Cancer Institute (NCI) has suggested a series of criteria to guide initial suspicion. It was the aim of this study to assess the perception of the risk of hereditary cancer according to the NCI criteria in our medical oncology service. We retrospectively analyzed the recordings of the family history in new cancer patients seen in our medical oncology service from January to November 2009, only 1 year before the implementation of our multidisciplinary hereditary cancer program. The family history was recorded in only 175/621 (28%) patients. A total of 119 (19%) patients met 1 or more NCI criteria (1 criterion, n = 91; 2 criteria, n = 23; 3 criteria, n = 4; and 4 criteria, n = 1), and only 14 (11.4%) patients were referred to genetic counseling. This study shows that few clinicians record the family history. The perception of the risk of hereditary cancer is low according to the NCI criteria in our medical oncology service. These findings can be explained by the lack of a multidisciplinary hereditary cancer program when the study was performed. Copyright © 2012 S. Karger AG, Basel.

  8. Tracking the Implementation of Electronic Medical Records in Dubai, United Arab Emirates, Using an Adoption Benchmarking Tool.

    Science.gov (United States)

    El-Hassan, Osama; Sharif, Amer; Al Redha, Mohammad; Blair, Iain

    2017-01-01

    In the United Arab Emirates (UAE), health services have developed greatly in the past 40 years. To ensure they continue to meet the needs of the population, innovation and change are required including investment in a strong e-Health infrastructure with a single transferrable electronic patient record. In this paper, using the Emirate of Dubai as a case study, we report on the Middle East Electronic Medical Record Adoption Model (EMRAM). Between 2011-2016, the number of participating hospitals has increased from 23 to 33. Currently, while 20/33 of hospitals are at Stage 2 or less, 10/33 have reached Stage 5. Also Dubai's median EMRAM score in 2016 (2.5) was higher than the scores reported from Australia (2.2), New Zealand (2.3), Malaysia (0.06), the Philippines (0.06) and Thailand (0.5). EMRAM has allowed the tracking of the progress being made by healthcare facilities in Dubai towards upgrading their information technology infrastructure and the introduction of electronic medical records.

  9. 42 CFR 491.10 - Patient health records.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Patient health records. 491.10 Section 491.10...: Conditions for Certification; and FQHCs Conditions for Coverage § 491.10 Patient health records. (a) Records... systematically organized. (3) For each patient receiving health care services, the clinic or center maintains a...

  10. Long-term pharmacotherapy for obesity in elderly patients: a retrospective evaluation of medical records from a specialized obesity outpatient clinic.

    Science.gov (United States)

    Horie, Nídia Celeste; Cercato, Cintia; Mancini, Marcio C; Halpern, Alfredo

    2010-06-01

    Obesity is a serious chronic disease and the prevalence of this condition is increasing among the elderly. Although the benefits of weight loss to improve control of associated diseases are well known in young adults, they are not in older patients. The use of anti-obesity drugs to promote weight loss is widespread in Brazil and other countries, and obesity specialists frequently prescribe medicines in doses and for durations previously unreported in the literature. Sibutramine, orlistat and amfepramone (diethylpropion) have been evaluated in clinical trials of more than 2 years' duration in adults, demonstrating safety and efficacy, but long-term studies in obesity treatment are absent for other drugs. The efficacy and safety of obesity pharmacotherapy among the elderly is unknown. To describe the experience of obesity pharmacotherapy in the elderly in a specialized obesity care setting in Brazil, with a focus on efficacy and safety. A retrospective evaluation was conducted on medical charts from an outpatient clinic of a specialized tertiary centre for the treatment of obesity. We included patients who had had at least one consultation between January and December 2007, were aged > or =60 years at the beginning of the treatment, had had at least 6 months of follow-up and had received a prescription of at least one potential weight-loss drug. Diagnoses reported on medical records were documented. Age, weight, height and body mass index (BMI) were recorded at admission, after 6, 12, 18 and 24 months, and at the last available visit. The medicines prescribed, together with the dose, duration of use, adverse effects and reasons for discontinuation, were documented. The group consisted of 44 women (86%) and 7 men (14%), with a mean +/- SD age of 65.2 +/- 4.5 years, weight of 95.3 +/- 12.5 kg and BMI of 38.5 +/- 4.3 kg/m2. The mean +/- SD time of follow-up was 39.3 +/- 26.4 months, and the mean weight loss was 6.65 kg (p or =5% was achieved by 64.71%, 63.64%, 62

  11. Evaluation of communication and acceptance of the patients by medical personnel

    Science.gov (United States)

    Włoszczak-Szubzda, Anna; Jarosz, Mirosław J; Goniewicz, Mariusz; Goniewicz, Krzysztof

    The low level of patient satisfaction recorded in many studies and, at the same time, the level of frustration and burnout, disclosed by medics in the perception of the patient as a ‘problem’, incline to look for the causes of inadequate relationship between physician and patient. The aim of this study was to evaluate the level of acceptance of the patient by the medical personnel. The research problem was the acceptance level which was within the range of the communication skills of the nurses and doctors. Another aim was to discover the factors determining this level of acceptance. Two methods were used in the research process: 1) a diagnostic survey regarding the medical, professional communication skills; 2) testing of professional self-esteem from the medical aspect. The study population consisted of a total of 1,244 respondents divided into the following groups: registered nurses and doctors (729), students of nursing and medical faculties (515). The results of the research showed that in most cases the acceptance of the patient by the medical staff was ‘conditional’, which translated into the level of frustration or lack of satisfaction with their profession, and ultimately into the level of burnout. The level of patient acceptance by medical staff (unconditional acceptance), depended primarily on age, followed by their profession. However, the relationship between this acceptance and gender and work experience was statistically insignificant. As the method to improve this situation, the expansion of education in the field of interpersonal communication is proposed, adding issues related with both the conditional and unconditional acceptance of the patient, as well as issues regarding how to deal with the patient from the aspect of disease and the psycho-socio-spiritual area.

  12. An analytical approach to characterize morbidity profile dissimilarity between distinct cohorts using electronic medical records

    OpenAIRE

    Schildcrout, Jonathan S.; Basford, Melissa A.; Pulley, Jill M.; Masys, Daniel R.; Roden, Dan M.; Wang, Deede; Chute, Christopher G.; Kullo, Iftikhar J.; Carrell, David; Peissig, Peggy; Kho, Abel; Denny, Joshua C.

    2010-01-01

    We describe a two-stage analytical approach for characterizing morbidity profile dissimilarity among patient cohorts using electronic medical records. We capture morbidities using the International Statistical Classification of Diseases and Related Health Problems (ICD-9) codes. In the first stage of the approach separate logistic regression analyses for ICD-9 sections (e.g., “hypertensive disease” or “appendicitis”) are conducted, and the odds ratios that describe adjusted differences in pre...

  13. 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. Copyright © 2014 Elsevier Inc. All rights reserved.

  14. Análise de prontuários de pacientes oncológicos quanto ao monitoramento auditivo Analyzing medical records of oncologic patients for audiological monitoring

    Directory of Open Access Journals (Sweden)

    Juliana Cunha da Costa

    2009-06-01

    Full Text Available OBJETIVO: realizar uma análise retrospectiva dos prontuários de pacientes oncológicos quanto ao monitoramento auditivo. MÉTODOS: foram utilizados os prontuários dos pacientes em atendimento durante os meses de setembro a novembro de 2006. A amostra constituiu-se de 25 prontuários de indivíduos com idade compreendida entre um e 53 anos. Foram analisados os dados quanto aos seguintes aspectos: idade, sexo, classificação do câncer, tempo de apresentação da doença, medicamentos utilizados, tempo de tratamento quimioterápico, doenças associadas, realização de avaliação otorrinolaringológica e audiológica. RESULTADOS: verificou-se a falta de acompanhamento audiológico e otorrinolaringológico. A Vincristina foi o medicamento ototóxico mais utilizado. O tipo de câncer de maior ocorrência no setor foi a Leucemia Linfocítica aguda. O tempo que os indivíduos apresentavam o câncer foi de aproximadamente 16 meses e o tempo de tratamento quimioterápico desses pacientes foi em torno de 11 meses. Observou-se, também, a presença de doenças associadas ao câncer nos indivíduos pesquisados. CONCLUSÃO: constatou-se a necessidade de se instalar programas de monitoramento auditivo nos setores que realizam quimioterapia em pacientes oncológicos, uma vez que este tratamento utiliza medicamentos ototóxicos em diversas patologias.PURPOSE: to accomplish a retrospective analysis for medical records of oncologic patient for audiological monitoring. METHODS: the patients' medical records in attendance were used from September to November, 2006. The sample constituted of 25 medical records of individuals with ages between 1 and 53-year old. The data were analyzed as for the following aspects: age, sex, cancer classification, time having the disease, used drugs, time of chemotherapy treatment, associated diseases, accomplishment of otorhinolaryngologic and audiologic evaluation. RESULTS: we verified the lack of audiologic and

  15. The impact of evidence-based sepsis guidelines on emergency department clinical practice: a pre-post medical record audit.

    Science.gov (United States)

    Romero, Bernadine; Fry, Margaret; Roche, Michael

    2017-11-01

    To explore the number of patients presenting with sepsis before and after guideline implementation; the impact of sepsis guidelines on triage assessment, emergency department management and time to antibiotics. Sepsis remains one of the leading causes of mortality and morbidity within hospitals. Globally, strategies have been implemented to reduce morbidity and mortality rates, which rely on the early recognition and management of sepsis. To improve patient outcomes, the New South Wales government in Australia introduced sepsis guidelines into emergency departments. However, the impact of the guidelines on clinical practice remains unclear. A 12-month pre-post retrospective randomised medical record audit of adult patients with a sepsis diagnosis. Data were extracted from the emergency department database and paper medical record. Data included patient demographic (age, gender), clinical information (time of arrival, triage code, seen by time, disposition, time to antibiotic, pathology, time to intravenous fluids) and patient assessment data (heart rate, respiratory rate, blood pressure, temperature, oxygen saturations, medication). This study demonstrated a statistically significant 230-minute reduction in time to antibiotics post implementation of the guidelines. The post group (n = 165) received more urgent triage categories (n = 81; 49·1%), a 758-minute reduction in mean time to second litre of intravenous fluids and an improvement in collection of lactate (n = 112, 67·9%), also statistically significant. The findings highlight the impact the guidelines can have on clinician decision-making and behaviour that support best practice and positive patient outcomes. The sepsis guidelines improved the early assessment, recognition and management of patients presenting with sepsis in one tertiary referral emergency department. The use of evidenced-based guidelines can impact clinical decision-making and behaviour, resulting in the translation and support of

  16. Medication Adherence and its Related Factors in Patients with Type II Diabetes

    Directory of Open Access Journals (Sweden)

    Behzad Gholamaliei

    2016-03-01

    Full Text Available Background and Objectives: Low levels of medication adherence in patients with type 2 diabetes is one of the greatest challenges in the treatment and control of diabetes. This study was designed to determine medication adherence and its related factors in patients with type II diabetes. Materials and Methods: In this cross-sectional study, a total of 300patients with type 2diabetes records in the health centers of Tuyserkan city were randomly selected in 2015. Data collection instrument was a self-made questionnaire, which consisted of factors related to the medication adherence. Questionnaires were completed after confirmation of validity and reliability, by interviews. To analyze the data, descriptive and inferential statistics (T-test, AnOVA, Simple and multiple linear regression were applied, using SPSS software, version 19. Results: Overall, %26.3 of patients were male and %73.7 were female. Also, %65 of patients were illiterate, %24 had some degree of symptoms, and %59.4 had poor medication adherence. There was a significant relationship between age, education, patient care and treatment expenditure, health care team and health system, therapy-related factors and condition-related factors, beliefs about illness, efficacy, and concerns about drugs and medication adherence (P < 0.05. Conclusions: This study showed that medication adherence in patients with diabetes was not suitable and individual, economical and social factors were influential.Therefore, the role of these factors must be considered when designing intervention programs.

  17. 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.

  18. Demographic Characteristics and Medical Service Use of Failed Back Surgery Syndrome Patients at an Integrated Treatment Hospital Focusing on Complementary and Alternative Medicine: A Retrospective Review of Electronic Medical Records

    Directory of Open Access Journals (Sweden)

    Hee Seung Choi

    2014-01-01

    Full Text Available Objective. To report the patient demographics and nonsurgical complementary and alternative medicine treatment used at a Korean medicine hospital for low back pain (LBP and/or sciatica after surgery. Methods. Medical records of patients who visited a spine-specialized Korean medicine hospital at 2 separate sites for continuous or recurrent LBP or sciatica following back surgery were reviewed. The demographics, MRI and/or CT scans, and treatments were assessed. Results. Of the total 707 patients, 62% were male and the average age was 50.20 years. Ninety percent of patients presented with LBP and 67% with sciatica. Eighty-four percent were diagnosed with herniated nucleus pulposus at time of surgery. Of these patients, 70% had pain recurrence 6 months or later, but 19% experienced no relief or immediate aggravation of pain after surgery. Many patients selected traditional Korean medicine treatment as primary means of postsurgery care (47%. When time to pain recurrence was short or pain persisted after surgery, return of symptoms at the same disc level and side was frequent. Conclusion. An integrative treatment model focusing on Korean medicine and used in conjunction with radiological diagnostics and conventional medicine is currently used as a treatment option for patients with pain after lumbar spine surgery.

  19. Electronic Medical Record Documentation of Driving Safety for Veterans with Diagnosed Dementia.

    Science.gov (United States)

    Vair, Christina L; King, Paul R; Gass, Julie; Eaker, April; Kusche, Anna; Wray, Laura O

    2018-01-01

    Many older adults continue to drive following dementia diagnosis, with medical providers increasingly likely to be involved in addressing such safety concerns. This study examined electronic medical record (EMR) documentation of driving safety for veterans with dementia (N = 118) seen in Veterans Affairs primary care and interdisciplinary geriatrics clinics in one geographic region over a 10-year period. Qualitative directed content analysis of retrospective EMR data. Assessment of known risk factors or subjective concerns for unsafe driving were documented in fewer than half of observed cases; specific recommendations for driving safety were evident for a minority of patients, with formal driving evaluation the most frequently documented recommendation by providers. Utilizing data from actual clinical encounters provides a unique snapshot of how driving risk and safety concerns are addressed for veterans with dementia. This information provides a meaningful frame of reference for understanding potential strengths and possible gaps in how this important topic area is being addressed in the course of clinical care. The EMR is an important forum for interprofessional communication, with documentation of driving risk and safety concerns an essential element for continuity of care and ensuring consistency of information delivered to patients and caregivers.

  20. Identification of fall predictors in the active elderly population from the routine medical records of general practitioners.

    Science.gov (United States)

    Lastrucci, Vieri; Lorini, Chiara; Rinaldi, Giada; Bonaccorsi, Guglielmo

    2018-03-01

    Aim To evaluate the possibility of determining predictors of falls in the active community-dwelling elderly from the routine medical records of the general practitioners (GPs). Time constraints and competing demands in the clinical encounters frequently undermine fall-risk evaluation. In the context of proactive primary healthcare, quick, and efficient tools for a preliminary fall-risk assessment are needed in order to overcome these barriers. The study included 1220 subjects of 65 years of age or older. Data were extracted from the GPs' patient records. For each subject, the following variables were considered: age, gender, diseases, and pharmacotherapy. Univariate and multivariable analyses have been conducted to identify the independent predictors of falls. Findings The mean age of the study population was 77.8±8.7 years for women and 74.9±7.3 years for men. Of the sample, 11.6% had experienced one or more falls in the previous year. The risk of falling was found to increase significantly (P<0.05) with age (OR=1.03; 95% CI=1.01-1.05), generalized osteoarthritis (OR=2.01; 95% CI=1.23-3.30), tinnitus (OR=4.14; 95% CI=1.25-13.74), cognitive impairment (OR=4.12; 95% CI=2.18-7.80), and two or more co-existing diseases (OR=5.4; 95% CI=1.68-17.39). Results suggest that it is possible to identify patients at higher risk of falling by going through the current medical records, without adding extra workload on the health personnel. In the context of proactive primary healthcare, the analysis of fall predictors from routine medical records may allow the identification of which of the several known and hypothesized risk factors may be more relevant for developing quick and efficient tools for a preliminary fall-risk assessment.

  1. From patient talk to physician notes-Comparing the content of medical interviews with medical records in a sample of outpatients in Internal Medicine.

    Science.gov (United States)

    Langewitz, Wolf A; Loeb, Yael; Nübling, Matthias; Hunziker, Sabina

    2009-09-01

    An increasing number of consultations are delivered in group practices, where a stable 1:1 relationship between patient and physician cannot be guaranteed. Therefore, correct documentation of the content of a consultation is crucial to hand over information from one health care professional to the next. We randomly selected 20 interviews from a series of 56 videotaped consultations with patients requesting a general check-up exam in the outpatient department of Internal Medicine at the University Hospital Basel. All patients actively denied having any symptoms or specific health concerns at the time they made their appointment. Videotapes were analysed with the Roter Interaction Analysis System (RIAS). Corresponding physician notes were analysed with a category check-list that contained the information related items from RIAS. Interviews contained a total of 9.002 utterances and lasted between 15 and 53min (mean duration: 37min). Patient-centred communication (Waiting, Echoing, Mirroring, Summarising) in the videos significantly correlated with the amount of information presented by patients: medical information (r=.57; p=.009), therapeutic information (r=.50; p=.03), psychosocial information (r=.41; p=.07), life style information (r=.52; p=.02), and with the sum of patient information (r=.64; p=.003). Even though there was a significant correlation between the amount of information from the video and information in physician's notes in some categories (patient gives medical information; Pearson's r=.45; p=.05, patient gives psychosocial information; Pearson's r=.49; p=.03), an inspection of the regression lines shows that a large extent of patient information is omitted from the charts. Physicians never discussed with patients whether information should be documented in the charts or omitted. The use of typical patient-centred techniques increases information gathered from patients. Physicians document only a small percentage of patient information in the charts

  2. Does sharing the electronic health record in the consultation enhance patient involvement? A mixed-methods study using multichannel video recording and in-depth interviews in primary care.

    Science.gov (United States)

    Milne, Heather; Huby, Guro; Buckingham, Susan; Hayward, James; Sheikh, Aziz; Cresswell, Kathrin; Pinnock, Hilary

    2016-06-01

    Sharing the electronic health-care record (EHR) during consultations has the potential to facilitate patient involvement in their health care, but research about this practice is limited. We used multichannel video recordings to identify examples and examine the practice of screen-sharing within 114 primary care consultations. A subset of 16 consultations was viewed by the general practitioner and/or patient in 26 reflexive interviews. Screen-sharing emerged as a significant theme and was explored further in seven additional patient interviews. Final analysis involved refining themes from interviews and observation of videos to understand how screen-sharing occurred, and its significance to patients and professionals. Eighteen (16%) of 114 videoed consultations involved instances of screen-sharing. Screen-sharing occurred in six of the subset of 16 consultations with interviews and was a significant theme in 19 of 26 interviews. The screen was shared in three ways: 'convincing' the patient of a diagnosis or treatment; 'translating' between medical and lay understandings of disease/medication; and by patients 'verifying' the accuracy of the EHR. However, patients and most GPs perceived the screen as the doctor's domain, not to be routinely viewed by the patient. Screen-sharing can facilitate patient involvement in the consultation, depending on the way in which sharing comes about, but the perception that the record belongs to the doctor is a barrier. To exploit the potential of sharing the screen to promote patient involvement, there is a need to reconceptualise and redesign the EHR. © 2014 The Authors Health Expectations Published by John Wiley & Sons Ltd.

  3. 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

  4. Stigma among California's Medical Marijuana Patients.

    Science.gov (United States)

    Satterlund, Travis D; Lee, Juliet P; Moore, Roland S

    2015-01-01

    The enactment of California's Proposition 215 stipulates that patients may use marijuana for medical reasons, provided that it is recommended by a physician. Yet, medical marijuana patients risk being stigmatized for this practice. This article examines the way in which medical marijuana patients perceive and process stigma, and how it affects their interactions and experiences with others. Eighteen semi-structured interviews of medical marijuana patients were carried out using a semi-structured interview guide. Most patients circumvented their own physicians in obtaining a recommendation to use medicinal marijuana, and also used a host of strategies in order to justify their medical marijuana use to family, friends, and colleagues in order to stave off potential stigma. The stigmatization of medical marijuana thus has a profound effect on how patients seek treatment, and whether they seek medical marijuana treatment at all.

  5. Discrepancies between perceptions of students and deans regarding the consequences of restricting students' use of electronic medical records on quality of medical education.

    Science.gov (United States)

    Solarte, Ivan; Könings, Karen D

    2017-03-13

    Electronic medical records (EMR) are more used in university hospitals, but the use of EMR by medical students at the workplace is still a challenge, because the conflict of interest between medical accountability for hospitals and quality of medical education programs for students. Therefore, this study investigates the use of EMR from the perspective of medical school deans and students, and determines their perceptions and concerns about consequences of restricted use of EMR by students on quality of education and patient care. We administered a large-scale survey about the existence of EMR, existing policies, students' use for learning, and consequences on patient care to 42 deans and 789 Residency Physician Applicants in a private university in Colombia. Data from 26 deans and 442 former graduated students were compared with independent t tests and chi square tests. Only half of medical schools had learning programs and policies about the use of EMR by students. Deans did not realize that students have less access to EMR than to paper-based MR. Perceptions of non-curricular learning opportunities how to write in (E)MR were significantly different between deans and students. Limiting students use of EMR has negative consequences on medical education, according to both deans and students, while deans worried significantly more about impact on patient care than students. Billing issues and liability aspects were their major concerns. There is a need for a clear policy and educational program on the use of EMR by students. Discrepancies between the planned curriculum by deans and the real clinical learning environment as experienced by students indicate suboptimal learning opportunities for students. Creating powerful workplace-learning experiences and resolving concerns on students use of EMR has to be resolved in a constructive collaboration way between the involved stakeholders, including also EMR designers and hospital administrators. We recommend intense

  6. Evaluating the Effectiveness of Community and Hospital Medical Record Integration on Management of Behavioral Health in the Emergency Department.

    Science.gov (United States)

    Ngo, Stephanie; Shahsahebi, Mohammad; Schreiber, Sean; Johnson, Fred; Silberberg, Mina

    2017-11-09

    This study evaluated the correlation of an emergency department embedded care coordinator with access to community and medical records in decreasing hospital and emergency department use in patients with behavioral health issues. This retrospective cohort study presents a 6-month pre-post analysis on patients seen by the care coordinator (n=524). Looking at all-cause healthcare utilization, care coordination was associated with a significant median decrease of one emergency department visit per patient (p management of behavioral health patients.

  7. Comparison of medication reconciliation and medication review: errors and clinical importance

    DEFF Research Database (Denmark)

    Bjeldbak-Olesen, Mette; Danielsen, Anja Gadsbølle; Tomsen, Dorthe Vilstrup

    2013-01-01

    in the patient record and the EMS. 15% of the discrepancies were potentially serious or fatal, 62% were potentially significant and 23% were potentially non-significant. A total of 129 DRPs were identified by medication review, 1.7 per patient. The most frequent DRPs were sub therapeutic dosage, inappropriate......Introduction: The objective of this study was to compare medication reconciliation and medication review based on number, type and severity of discrepancies and drug-re­lated problems (DRPs), denoted errors. Material and methods: This was a retrospective study conducted at the Department...... of Cardiology, Hillerød Hos­pital. Medication reconciliation compared the prescriptions in patient records, an electronic medication system (EMS) and in discharge summaries (DS). The medication review was based on the EMS. The two methods were performed on the same data material. To assess the clinical...

  8. 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.

  9. Develop security architecture for both in-house healthcare information systems and electronic patient record

    Science.gov (United States)

    Zhang, Jianguo; Chen, Xiaomeng; Zhuang, Jun; Jiang, Jianrong; Zhang, Xiaoyan; Wu, Dongqing; Huang, H. K.

    2003-05-01

    In this paper, we presented a new security approach to provide security measures and features in both healthcare information systems (PACS, RIS/HIS), and electronic patient record (EPR). We introduced two security components, certificate authoring (CA) system and patient record digital signature management (DSPR) system, as well as electronic envelope technology, into the current hospital healthcare information infrastructure to provide security measures and functions such as confidential or privacy, authenticity, integrity, reliability, non-repudiation, and authentication for in-house healthcare information systems daily operating, and EPR exchanging among the hospitals or healthcare administration levels, and the DSPR component manages the all the digital signatures of patient medical records signed through using an-symmetry key encryption technologies. The electronic envelopes used for EPR exchanging are created based on the information of signers, digital signatures, and identifications of patient records stored in CAS and DSMS, as well as the destinations and the remote users. The CAS and DSMS were developed and integrated into a RIS-integrated PACS, and the integration of these new security components is seamless and painless. The electronic envelopes designed for EPR were used successfully in multimedia data transmission.

  10. Electronic medical records in humanitarian emergencies - the development of an Ebola clinical information and patient management system.

    Science.gov (United States)

    Jobanputra, Kiran; Greig, Jane; Shankar, Ganesh; Perakslis, Eric; Kremer, Ronald; Achar, Jay; Gayton, Ivan

    2016-01-01

    By November 2015, the West Africa Ebola epidemic had caused 28598 infections and 11299 deaths in the three countries most affected. The outbreak required rapid innovation and adaptation. Médecins sans Frontières (MSF) scaled up its usual 20-30 bed Ebola management centres (EMCs) to 100-300 beds with over 300 workers in some settings. This brought challenges in patient and clinical data management resulting from the difficulties of working safely with high numbers of Ebola patients. We describe a project MSF established with software developers and the Google Social Impact Team to develop context-adapted tools to address the challenges of recording Ebola clinical information. We share the outcomes and key lessons learned in innovating rapidly under pressure in difficult environmental conditions. Information on adoption, maintenance, and data quality was gathered through review of project documentation, discussions with field staff and key project stakeholders, and analysis of tablet data. In March 2015, a full prototype was deployed in Magburaka EMC, Sierra Leone. Inpatient data were captured on 204 clinical interactions with 34 patients from 5 March until 10 April 2015. Data continued to also be recorded on paper charts, creating theoretically identical record "pairs" on paper and tablet. 83 record pairs for 33 patients with 22 data items (temperature and symptoms) per pair were analysed. The overall Kappa coefficient for agreement between sources was 0.62, but reduced to 0.59 when rare bleeding symptoms were excluded, indicating moderate to good agreement. The time taken to deliver the product was more than that anticipated by MSF (7 months versus 6 weeks). Deployment of the tablet coincided with a dramatic drop in patient numbers and thus had little impact on patient care. We have identified lessons specific to humanitarian-technology collaborative projects and propose a framework for emergency humanitarian innovation. Time and effort is required to bridge

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

    Science.gov (United States)

    Nemeth, Lynne S; Feifer, Chris; Stuart, Gail W; Ornstein, Steven M

    2008-01-16

    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). 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. 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 improvement, leading to an iterative cycle of goal setting

  12. Health Care Consumer's Perception of the Electronic Medical Record

    African Journals Online (AJOL)

    Method: A structured questionnaire was developed, validated and utilized in this quantitative research project. Quantitative data were collected ... Electronic Medical Records (EMR), as a health information technology innovation, has ... EMR will provide a highly effective, reliable, secure, and innovative information system.

  13. Are patients reliable when self-reporting medication use? Validation of structured drug interviews and home visits by drug analysis and prescription data in acutely hospitalized patients

    DEFF Research Database (Denmark)

    Glintborg, Bente; Hillestrøm, Peter René; Olsen, Lenette Holm

    2007-01-01

    were compared to the patients' self-reported medication history. Information on prescribed drugs dispensed from any Danish pharmacy was collected from nationwide real-time pharmacy records. The authors performed home visits in a subgroup of 115 patients 4 weeks after their discharge. Stored drugs were......The medication history among hospitalized patients often relies on patients' self-reports due to insufficient communication between health care professionals. The aim of the present study was to estimate the reliability of patients' self-reported medication use. Five hundred patients admitted...... to an acute medical department at a Danish university hospital were interviewed on the day of admission about their recent medication use. Blood samples drawn immediately after admission were screened for contents of 5 drugs (digoxin, bendroflumethiazide, amlodipine, simvastatin, glimepiride), and the results...

  14. Generating demand for pharmacist-provided medication therapy management: identifying patient-preferred marketing strategies.

    Science.gov (United States)

    Garcia, Gladys M; Snyder, Margie E; McGrath, Stephanie Harriman; Smith, Randall B; McGivney, Melissa Somma

    2009-01-01

    To identify effective strategies for marketing pharmacist-provided medication therapy management (MTM) services to patients in a self-insured employer setting. Qualitative study. University of Pittsburgh during March through May 2008. 26 university employees taking at least one chronic medication. Three focus group sessions were conducted using a semistructured topic guide to facilitate the discussion. Employees' perceived medication-related needs, perceived benefits of pharmacist-provided MTM, potential barriers for employee participation in MTM, and effective strategies for marketing MTM. Participants reported concerns with timing of doses, medication costs, access, and ensuring adherence. Participants generally felt positively toward pharmacists; however, the level of reported patient contact with pharmacists varied among participants. Some participants questioned pharmacists' education and qualifications for this enhanced role in patient care. Perceived benefits of MTM noted by participants included the opportunity to obtain personalized information about their medications and the potential for improved communication among their health providers. Barriers to patient participation were out-of-pocket costs and lack of time for MTM visits. Participants suggested use of alternative words to describe MTM and marketing approaches that involve personal contact. Pharmacists should emphasize parts of MTM that patients feel are most beneficial (i.e., provision of a personal medication record) and use patient-friendly language to describe MTM when marketing their practice. Patients will need greater exposure to the concept of MTM and the pharmacists' role in order to correctly describe and assign value to this type of pharmacist patient care practice.

  15. 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. © The Author(s) 2016.

  16. Casebook: a virtual patient iPad application for teaching decision-making through the use of electronic health records.

    Science.gov (United States)

    Bloice, Marcus D; Simonic, Klaus-Martin; Holzinger, Andreas

    2014-08-07

    Virtual Patients are a well-known and widely used form of interactive software used to simulate aspects of patient care that students are increasingly less likely to encounter during their studies. However, to take full advantage of the benefits of using Virtual Patients, students should have access to multitudes of cases. In order to promote the creation of collections of cases, a tablet application was developed which makes use of electronic health records as material for Virtual Patient cases. Because electronic health records are abundantly available on hospital information systems, this results in much material for the basis of case creation. An iPad-based Virtual Patient interactive software system was developed entitled Casebook. The application has been designed to read specially formatted patient cases that have been created using electronic health records, in the form of X-ray images, electrocardiograms, lab reports, and physician notes, and present these to the medical student. These health records are organised into a timeline, and the student navigates the case while answering questions regarding the patient along the way. Each health record can also be annotated with meta-information by the case designer, such as insight into the thought processes and the decision-making rationale of the physician who originally worked with the patient. Students learn decision-making skills by observing and interacting with real patient cases in this simulated environment. This paper discusses our approach in detail. Our group is of the opinion that Virtual Patient cases, targeted at undergraduate students, should concern patients who exhibit prototypical symptoms of the kind students may encounter when beginning their first medical jobs. Learning theory research has shown that students learn decision-making skills best when they have access to multitudes of patient cases and it is this plurality that allows students to develop their illness scripts effectively

  17. Evaluating the utility of provider-recorded clinical status in the medical records of HIV-positive adults in a limited-resource setting

    Science.gov (United States)

    Stonbraker, Samantha; Befus, Montina; Nadal, Leonel Lerebours; Halpern, Mina; Larson, Elaine

    2016-01-01

    Provider-reported summaries of clinical status may assist with clinical management of HIV in resource poor settings if they reflect underlying biological processes associated with HIV disease progression. However, their ability to do so is rarely evaluated. Therefore, we aimed to assess the relationship between a provider-recorded summary of clinical status and indicators of HIV progression. Data were abstracted from 201 randomly selected medical records at a large HIV clinic in the Dominican Republic. Multivariable logistic regressions were used to examine the relationship between provider-assigned clinical status and demographic (gender, age, nationality, education) and clinical factors (reported medication adherence, CD4 cell count, viral load). The mean age of patients was 41.2 (SD = ±10.9) years and most were female (n = 115, 57%). None of the examined characteristics were significantly associated with provider-recorded clinical status. Higher CD4 cell counts were more likely for females (OR = 2.2 CI: 1.12–4.31) and less likely for those with higher viral loads (OR = 0.33 CI: 0.15–0.72). Poorer adherence and lower CD4 cell counts were significantly associated with higher viral loads (OR = 4.46 CI: 1.11–20.29 and 6.84 CI: 1.47–37.23, respectively). Clinics using provider-reported summaries of clinical status should evaluate the performance of these assessments to ensure they are associated with biologic indicators of disease progression. PMID:27495146

  18. Information on actual medication use and drug-related problems in older patients: questionnaire or interview?

    Science.gov (United States)

    Willeboordse, Floor; Grundeken, Lucienne H; van den Eijkel, Lisanne P; Schellevis, François G; Elders, Petra J M; Hugtenburg, Jacqueline G

    2016-04-01

    Information on medication use and drug-related problems is important in the preparation of clinical medication reviews. Critical information can only be provided by patients themselves, but interviewing patients is time-consuming. Alternatively, patient information could be obtained with a questionnaire. In this study the agreement between patient information on medication use and drug-related problems in older patients obtained with a questionnaire was compared with information obtained during an interview. General practice in The Netherlands. A questionnaire was developed to obtain information on actual medication use and drug-related problems. Two patient groups ≥65 years were selected based on general practitioner electronic medical records in nine practices; I. polypharmacy and II. ≥1 predefined general geriatric problems. Eligible patients were asked to complete the questionnaire and were interviewed afterwards. Agreement on information on medication use and drug-related problems collected with the questionnaire and interview was calculated. Ninety-seven patients participated. Of all medications used, 87.6 % (95 % CI 84.7-90.5) was reported identically in the questionnaire and interview. Agreement for the complete medication list was found for 45.4 % (95 % CI 35.8-55.3) of the patients. On drug-related problem level, agreement between questionnaire and interview was 75 %. Agreement tended to be lower in vulnerable patients characterized by ≥4 chronic diseases, ≥10 medications used and low health literacy. Information from a questionnaire showed reasonable agreement compared with interviewing. The patients reported more medications and drug-related problems in the interview than the questionnaire. Taking the limitations into account, a questionnaire seems a suitable tool for medication reviews that may replace an interview for most patients.

  19. Design of a consumer health record for supporting the patient-centered management of chronic diseases.

    NARCIS (Netherlands)

    de Clerq, P.A.; Hasman, A.; Wolffenbuttel, B.H.R.

    2001-01-01

    : Medinfo 2001;10(Pt 2):1445-9 Related Articles, Books, LinkOut Design of a consumer health record for supporting the patient-centered management of chronic diseases. de Clercq PA, Hasman A, Wolffenbuttel BH. Department of Medical Informatics, University of Maastricht, Maastricht, The Netherlands.

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

    CSIR Research Space (South Africa)

    Sikhondze, NC

    2016-05-01

    Full Text Available of Electronic Medical Records (EMR) systems in developed and developing countries. There is a direct relationship between the income of the country and the use of electronic information and communication systems as part of healthcare systems hence the division...

  1. Stigma Among California's Medical Marijuana Patients

    OpenAIRE

    Satterlund, Travis D.; Lee, Juliet P.; Moore, Roland S.

    2015-01-01

    The enactment of California's Proposition 215 stipulates that patients may use marijuana for medical reasons, provided that it is recommended by a physician. Yet, medical marijuana patients risk being stigmatized for this practice. This paper examines the way in which medical marijuana patients perceive and process stigma, and how it affects their interactions and experiences with others. Eighteen semi-structured interviews of medical marijuana patients were carried out using a semi-structure...

  2. 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.

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

    DEFF Research Database (Denmark)

    Pantazos, Kostas; Lauesen, Søren; Lippert, Søren

    2016-01-01

    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...

  4. Identifying medication-related needs of HIV patients: foundation for community pharmacist-based services

    Directory of Open Access Journals (Sweden)

    Yardlee Kauffman

    2014-01-01

    Full Text Available Background: Patients living with HIV/AIDS have complex medication regimens. Pharmacists within community pharmacy settings can have a role managing patients living with HIV/AIDS. Patients' perspectives surrounding implementation about community pharmacist-based services is needed as limited information is available. Objective: To identify medication-related needs of HIV-infected patients who receive prescriptions from a community pharmacy. To determine patient perspectives and knowledge of community pharmacist-based services. Methods: A qualitative research study involving in-depth, semi-structured interviews with patients was conducted. Inclusion criteria included: HIV positive men and women at least 18 years of age who receive care at a HIV clinic, currently take medication(s and use a community pharmacy for all prescription fills. Patients were recruited from one urban and one rural health center. Patients answered questions about their perceptions and knowledge about the role and value of pharmacy services and completed a demographic survey. The recordings of the interviews were transcribed verbatim and were analyzed using principles of Grounded Theory. Results: Twenty-nine interviews were conducted: 15 participants from the urban site and 14 from the rural site. Five main themes emerged including: patients experience ongoing and varying medication-related needs; patients desire a pharmacist who is caring, knowledgeable and integrated with health care providers; patients expect ready access to drug therapy; patients value an individualized patient encounter, and patients need to be informed that a pharmacist-service exists. Conclusion: Patients with HIV value individualized and personal encounters with pharmacists at time intervals that are convenient for the patient. Patients felt that a one-on-one encounter with a pharmacist would be most valuable when initiating or modifying medication therapy. These patient perspectives can be useful for

  5. Estudo de incidência de eventos adversos hospitalares, Rio de Janeiro, Brasil: avaliação da qualidade do prontuário do paciente Incidence of in-hospital adverse events in the State of Rio de Janeiro, Brazil: Evaluation of patient medical record

    Directory of Open Access Journals (Sweden)

    Ana Luiza Braz Pavão

    2011-12-01

    study based on the information collected from medical record review during the incidence study. An evaluation score of completeness, measuring the proportion of absent information was applied, based on the following items: excellent (less than 5%, good (5% - 10%, moderate (11% - 20%, bad (21% - 50%, and very bad (more than 50%. Proportions and 95%confidence intervals were calculated for each variable obtained from medical records. Analysis was developed for the whole group of patients, by hospital groups, and by patients with and without AE. For analyzing the group of variables, means were estimated and the t-student's test was applied for comparisons. The Chi-squared test and Fisher's statistics were applied for comparing patients with and without AE. RESULTS: The quality of information obtained from patient medical records was considered bad in the group of patients as a whole. Variables with the highest proportion of absent information were: "Nurse's first evaluation of the patient" (63.9% and "Social worker's evaluation" (80%. Hospital 3 had the best results in terms of quality of medical records and hospital 1 had the worst results. The quality of medical records of patients with AE was better than the quality of medical records of patients that had no AE. CONCLUSIONS: Variables considered essential for patient's healthcare were not well documented. Measures to develop quality of medical records are necessary to improve patient's healthcare.

  6. Mass Medication Clinic (MMC) Patient Medical Assistant (PMA) System Training Initiative

    Science.gov (United States)

    2007-06-01

    AD_________________ Award Number: W81XWH-06-2-0045 TITLE: Mass Medication Clinic (MMC) Patient ...SUBTITLE 5a. CONTRACT NUMBER Mass Medication Clinic (MMC) Patient Medical Assistant (PMA) System Training Initiative 5b. GRANT NUMBER W81XWH-06-2...sections will describe the events, results, and accomplishments of this study. With validation through this project the Patient Medical Assistant

  7. Evaluation of Data Recording at Teaching Hospitals

    Directory of Open Access Journals (Sweden)

    Hasan Karbasi

    2009-02-01

    Full Text Available Background and purpose: Medical records of patients have an undeniable role on education, research and evaluation of health care delivery, and also could be used as reliable documents of past in casesof patients’ legal complains. This study was done to evaluate medical data recording at teaching hospital of Birjand University of Medical Sciences in 2004.Methods: In this descriptive-analytic study, 527 patients’ records of patients who had been discharged from general wards of the hospitals after 24 hours of hospitalization were randomly selected. 18 standard titles of records include in each patient’s record were evaluated using checklists. Data were analyzed using frequency distribution tables, independent t-test and Chi-square test.Results: Items on records’ titles were completed in a range of 0-100%. Titles of neonates and nursing care with 96% completeness were the most completed ones~ Titles of recovery, pre-delivery care, medical history, summary, and progress notes with 50% to 74% completeness were categorized as moderately completed titles; and titles of vital signs, pre-operation care and operation report were weak. Records of the infectious diseases ward were the most completed records (68% and the least completed were from ophthmology ward (35.8%. There were significant differences between the hospitals and between different wards.Conclusion: Results of this study show the need for further education on record writing, taking medical history, and order writing and more importantly the need for a system of continuous monitoringof the records.Keywords: MEDICAL RECORD, TEACHING HOSPITAL, EVALUATION

  8. 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

  9. Exploiting Multimodal Biometrics in E-Privacy Scheme for Electronic Health Records

    OpenAIRE

    Omotosho, Adebayo; Adegbola, Omotanwa; Adelakin, Barakat; Adelakun, Adeyemi; Emuoyibofarhe, Justice

    2015-01-01

    Existing approaches to protect the privacy of Electronic Health Records are either insufficient for existing medical laws or they are too restrictive in their usage. For example, smart card-based encryption systems require the patient to be always present to authorize access to medical records. Questionnaires were administered by 50 medical practitioners to identify and categorize different Electronic Health Records attributes. The system was implemented using multi biometrics of patients to ...

  10. Implications of Patient Portal Transparency in Oncology: Qualitative Interview Study on the Experiences of Patients, Oncologists, and Medical Informaticists.

    Science.gov (United States)

    Alpert, Jordan M; Morris, Bonny B; Thomson, Maria D; Matin, Khalid; Brown, Richard F

    2018-03-26

    Providing patients with unrestricted access to their electronic medical records through patient portals has impacted patient-provider communication and patients' personal health knowledge. However, little is known about how patient portals are used in oncology. The aim of this study was to understand attitudes of the portal's adoption for oncology and to identify the advantages and disadvantages of using the portal to communicate and view medical information. In-depth semistructured interviews were conducted with 60 participants: 35 patients, 13 oncologists, and 12 medical informaticists. Interviews were recorded, transcribed, and thematically analyzed to identify critical incidents and general attitudes encountered by participants. Two primary themes were discovered: (1) implementation practices influence attitudes, in which the decision-making and execution process of introducing portals throughout the hospital did not include the input of oncologists. Lack of oncologists' involvement led to a lack of knowledge about portal functionality, such as not knowing the time period when test results would be disclosed to patients; (2) perceptions of portals as communication tools varies by user type, meaning that each participant group (patients, oncologists, and medical informaticists) had varied opinions about how the portal should be used to transmit and receive information. Oncologists and medical informaticists had difficulty understanding one another's culture and communication processes in their fields, while patients had preferences for how they would like to receive communication, but it largely depended upon the type of test being disclosed. The majority of patients (54%, 19/35) who participated in this study viewed lab results or scan reports via the portal before being contacted by a clinician. Most were relatively comfortable with this manner of disclosure but still preferred face-to-face or telephone communication. Findings from this study indicate that

  11. Wireless connection of continuous glucose monitoring system to the electronic patient record

    Science.gov (United States)

    Murakami, Alexandre; Gutierrez, Marco A.; Lage, Silvia G.; Rebelo, Marina S.; Granja, Luiz A. R.; Ramires, Jose A. F.

    2005-04-01

    The control of blood sugar level (BSL) at near-normal levels has been documented to reduce both acute and chronic complications of diabetes mellitus. Recent studies suggested, the reduction of mortality in a surgical intensive care unit (ICU), when the BSL are maintained at normal levels. Despite of the benefits appointed by these and others clinical studies, the strict BSL control in critically ill patients suffers from some difficulties: a) medical staff need to measure and control the patient"s BSL using blood sample at least every hour. This is a complex and time consuming task; b) the inaccuracy of standard capillary glucose monitoring (fingerstick) in hypotensive patients and, if frequently used to sample arterial or venous blood, may lead to excess phlebotomy; c) there is no validated procedure for continuously monitoring of BSL levels. This study used the MiniMed CGMS in ill patients at ICU to send, in real-time, BSL values to a Web-Based Electronic Patient Record. The BSL values are parsed and delivered through a wireless network as an HL7 message. The HL7 messages with BSL values are collected, stored into the Electronic Patient Record and presented into a bed-side monitor at the ICU together with other relevant patient information.

  12. 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...... not adequately support complex clinical work. While the CPOMR can be used for patients with few, simple problems who are admitted for only a short time, the CPOMR is not useful for patients with a complex set of problems or for patients admitted for longer periods of time. This is in accordance with criticism...

  13. Prescription data improve the medication history in primary care

    DEFF Research Database (Denmark)

    Glintborg, Bente; Andersen, S K; Poulsen, H E

    2010-01-01

    Incomplete medication lists increase the risk of medication errors and adverse drug effects. In Denmark, dispensing data and pharmacy records are available directly online to treating physicians. We aimed (1) to describe if use of pharmacy records improved the medication history among patients...... consulting their general practitioner and (2) to characterise inconsistencies between the medication history reported by the patient and the general practitioner's recordings....

  14. Identification of Units and Other Terms in Czech Medical Records

    Czech Academy of Sciences Publication Activity Database

    Zvára Jr., Karel; Kašpar, Václav

    2010-01-01

    Roč. 6, č. 1 (2010), s. 78-82 ISSN 1801-5603 R&D Projects: GA MŠk(CZ) 1M06014 Institutional research plan: CEZ:AV0Z10300504 Keywords : natural language processing * healthcare documentation * medical reports * EHR * finite-state machine * regular expression Subject RIV: IN - Informatics, Computer Science http://www.ejbi.org/en/ejbi/article/61-en-identification-of-units-and-other-terms-in-czech-medical-records.html

  15. 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...

  16. The impact of health coaching on medication adherence in patients with poorly controlled diabetes, hypertension, and/or hyperlipidemia: a randomized controlled trial.

    Science.gov (United States)

    Thom, David H; Willard-Grace, Rachel; Hessler, Danielle; DeVore, Denise; Prado, Camille; Bodenheimer, Thomas; Chen, Ellen

    2015-01-01

    Lack of concordance between medications listed in the medical record and taken by the patient contributes to poor outcomes. We sought to determine whether patients who received health coaching by medical assistants improved their medication concordance and adherence. This was a nonblinded, randomized, controlled, pragmatic intervention trial. English- or Spanish-speaking patients, age 18 to 75 years, with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were enrolled from 2 urban safety net clinics and randomized to receive 12 months of health coaching versus usual care. Outcomes included concordance between medications documented in the medical record and those reported by the patient and adherence based on the patient-reported number of days (of the last 7) on which patient took all prescribed medications. The proportion of medications completely concordant increased in the coached group versus the usual care group (difference in change, 10%; P = .05). The proportion of medications listed in the chart but not taken significantly decreased in the coached group compared with the usual care group (difference in change, 17%; P = .013). The mean number of adherent days increased in the coached but not in the usual care group (difference in change, 1.08; P coaching by medical assistants significantly increases medication concordance and adherence. © Copyright 2015 by the American Board of Family Medicine.

  17. The organization of information in electronic patient record under the perspective of usability recommendations: proposition of organization of information.

    Directory of Open Access Journals (Sweden)

    Tatiana Tissa Kawakami

    2017-10-01

    Full Text Available Introduction: Among the various areas of studies, health information is highlighted in this study. More specifically, the patient's electronic medical records and issues related to it’s informational organization and usability. Objectives: suggest Usability recommendations applicable to the Electronic Patient Record. More specifically, identify, according to the specialized literature, recommendations of Usability, as well as to develop a checklist with recommendations of Usability for the Electronic Patient Record. Methodology: the study’s basic purpose is the theoretical nature. The deductive method of documental delimitation was chosen. Results: elaboration of checklist with recommendations of Usability for Electronic Patient Records. Conclusion: Usability recommendations can be used to improve electronic patient records. However, it should be noted that knowledge in the scope of Information Science should be considered and summed up, since a great deal of content related to Usability refers to operational and visual aspects of the interface, not clearly or directly contemplating the issues related to information.

  18. Overcoming barriers to implementing patient-reported outcomes in an electronic health record: a case report.

    Science.gov (United States)

    Harle, Christopher A; Listhaus, Alyson; Covarrubias, Constanza M; Schmidt, Siegfried Of; Mackey, Sean; Carek, Peter J; Fillingim, Roger B; Hurley, Robert W

    2016-01-01

    In this case report, the authors describe the implementation of a system for collecting patient-reported outcomes and integrating results in an electronic health record. The objective was to identify lessons learned in overcoming barriers to collecting and integrating patient-reported outcomes in an electronic health record. The authors analyzed qualitative data in 42 documents collected from system development meetings, written feedback from users, and clinical observations with practice staff, providers, and patients. Guided by the Unified Theory on the Adoption and Use of Information Technology, 5 emergent themes were identified. Two barriers emerged: (i) uncertain clinical benefit and (ii) time, work flow, and effort constraints. Three facilitators emerged: (iii) process automation, (iv) usable system interfaces, and (v) collecting patient-reported outcomes for the right patient at the right time. For electronic health record-integrated patient-reported outcomes to succeed as useful clinical tools, system designers must ensure the clinical relevance of the information being collected while minimizing provider, staff, and patient burden. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  19. Design and implementation of an affordable, public sector electronic medical record in rural Nepal

    Directory of Open Access Journals (Sweden)

    Anant Raut

    2017-06-01

    Over the course of 18 months, we were able to develop, deploy and iterate upon the electronic medical record, and then deploy the refined product at an additional facility within only four weeks. Our experience suggests the feasibility of an integrated electronic medical record for public sector care delivery even in settings of rural poverty.

  20. Electronic medical records and efficiency and productivity during office visits.

    Science.gov (United States)

    Furukawa, Michael F

    2011-04-01

    To estimate the relationship between electronic medical record (EMR) use and efficiency of utilization and provider productivity during visits to US office-based physicians. Cross-sectional analysis of the 2006-2007 National Ambulatory Medical Care Survey. The sample included 62,710 patient visits to 2625 physicians. EMR systems included demographics, clinical notes, prescription orders, and laboratory and imaging results. Efficiency was measured as utilization of examinations, laboratory tests, radiology procedures, health education, nonmedication treatments, and medications. Productivity was measured as total services provided per 20-minute period. Survey-weighted regressions estimated association of EMR use with services provided, visit intensity/duration, and productivity. Marginal effects were estimated by averaging across all visits and by major reason for visit. EMR use was associated with higher probability of any examination (7.7%, 95% confidence interval [CI] = 2.4%, 13.1%); any laboratory test (5.7%, 95% CI = 2.6%, 8.8%); any health education (4.9%, 95% CI = 0.2%, 9.6%); and fewer laboratory tests (-7.1%, 95% CI = -14.2%, -0.1%). During pre/post surgery visits, EMR use was associated with 7.3% (95% CI= -12.9%, -1.8%) fewer radiology procedures. EMR use was not associated with utilization of nonmedication treatments and medications, or visit duration. During routine visits for a chronic problem, EMR use was associated with 11.2% (95% CI = 5.7%, 16.8%) more diagnostic/screening services provided per 20-minute period. EMR use had a mixed association with efficiency and productivity during office visits. EMRs may improve provider productivity, especially during visits for a new problem and routine chronic care.

  1. To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

    Directory of Open Access Journals (Sweden)

    van der Wal Gerrit

    2011-02-01

    Full Text Available Abstract Background Patient record review is believed to be the most useful method for estimating the rate of adverse events among hospitalised patients. However, the method has some practical and financial disadvantages. Some of these disadvantages might be overcome by using existing reporting systems in which patient safety issues are already reported, such as incidents reported by healthcare professionals and complaints and medico-legal claims filled by patients or their relatives. The aim of the study is to examine to what extent the hospital reporting systems cover the adverse events identified by patient record review. Methods We conducted a retrospective study using a database from a record review study of 5375 patient records in 14 hospitals in the Netherlands. Trained nurses and physicians using a method based on the protocol of The Harvard Medical Practice Study previously reviewed the records. Four reporting systems were linked with the database of reviewed records: 1 informal and 2 formal complaints by patients/relatives, 3 medico-legal claims by patients/relatives and 4 incident reports by healthcare professionals. For each adverse event identified in patient records the equivalent was sought in these reporting systems by comparing dates and descriptions of the events. The study focussed on the number of adverse event matches, overlap of adverse events detected by different sources, preventability and severity of consequences of reported and non-reported events and sensitivity and specificity of reports. Results In the sample of 5375 patient records, 498 adverse events were identified. Only 18 of the 498 (3.6% adverse events identified by record review were found in one or more of the four reporting systems. There was some overlap: one adverse event had an equivalent in both a complaint and incident report and in three cases a patient/relative used two or three systems to complain about an adverse event. Healthcare professionals

  2. Investigating the recording and accuracy of fluid balance monitoring in critically ill patients

    Directory of Open Access Journals (Sweden)

    Annette Diacon

    2014-11-01

    Full Text Available Background. The accurate assessment of fluid balance data collected during physical assessment as well as during monitoring and record-keeping forms an essential part of the baseline patient information that guides medical and nursing interventions aimed at achieving physiological stability in patients. An informal audit of 24-hour fluid balance records in a local intensive care unit (ICU showed that seven out of ten fluid balance calculations were incorrect.Objective. To identify and describe current clinical nursing practice in fluid balance monitoring and measurement accuracy in ICUs, conducted as part of a broader study in partial fulfilment of a Master of Nursing degree.Methods. A quantitative approach utilising a descriptive, exploratory study design was applied. An audit of 103 ICU records was conducted to establish the current practices and accuracy in recording of fluid balance monitoring. Data were collected using a purpose-designed tool based on relevant literature and practice experience. Results. Of the original recorded fluid balance calculations, 79% deviated by more than 50 mL from the audited calculations. Further­more, a significant relationship was shown between inaccurate fluid balance calculation and administration of diuretics (p=0.01. Conclusion. The majority of fluid balance records were incorrectly calculated.

  3. Review by a local medical research ethics committee of the conduct of approved research projects, by examination of patients' case notes, consent forms, and research records and by interview.

    Science.gov (United States)

    Smith, T; Moore, E J; Tunstall-Pedoe, H

    1997-05-31

    To monitor the conduct of medical research projects that have already been approved by the local medical research ethics committee. Follow up study of ethically approved studies (randomly selected from all the studies approved in the previous year) by examination of patients' case notes, consent forms, and research records and by interview of the researchers at their workplace. Tayside, Scotland (mixed rural and urban population). 30 research projects approved by Tayside local medical research ethics committee. Adherence to the agreed protocol, particularly for recruitment (obtaining and recording informed consent) and for specific requirements of the ethics committee, including notification of changes to the protocol and of adverse events. In one project only oral consent had been obtained, and in a quarter of the studies one or more consent forms were incorrectly completed. Inadequate filing of case notes in five studies and of consent forms in six made them unavailable for scrutiny. Adverse events were reported, but there was a general failure to report the abandoning or non-starting of projects in two studies the investigators failed to notify a change in the responsible researcher. Monitoring of medical research by local medical research ethics committees promotes and preserves ethical standards, protects subjects and researchers, discourages fraud, and has the support of investigators. We recommend that 10% of projects should undergo on-site review, with all others monitored by questionnaire. This would require about six person hours of time and a salary bill of 120 pounds per study monitored.

  4. An audit of the reliability of influenza vaccination and medical information extracted from eHealth records in general practice.

    Science.gov (United States)

    Regan, Annette K; Gibbs, Robyn A; Effler, Paul V

    2018-05-31

    To evaluate the reliability of information in general practice (GP) electronic health records (EHRs), 2100 adult patients were randomly selected for interview regarding the presence of specific medical conditions and recent influenza vaccination. Agreement between self-report and data extracted from EHRs was compared using Cohen's kappa coefficient (k) and interpreted in accordance with Altman's Kappa Benchmarking criteria; 377 (18%) patients declined participation, and 608 (29%) could not be contacted. Of 1115 (53%) remaining, 856 (77%) were active patients (≥3 visits to the GP practice in the last two years) who provided complete information for analysis. Although a higher proportion of patients self-reported being vaccinated or having a medical condition compared to the EHR (50.7% vs 36.9%, and 39.4% vs 30.3%, respectively), there was "good" agreement between self-report and EHR for both vaccination status (κ = 0.67) and medical conditions (κ = 0.66). These findings suggest EHR may be useful for public health surveillance. Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.

  5. 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.

  6. Predictive Modeling of Physician-Patient Dynamics That Influence Sleep Medication Prescriptions and Clinical Decision-Making

    Science.gov (United States)

    Beam, Andrew L.; Kartoun, Uri; Pai, Jennifer K.; Chatterjee, Arnaub K.; Fitzgerald, Timothy P.; Shaw, Stanley Y.; Kohane, Isaac S.

    2017-02-01

    Insomnia remains under-diagnosed and poorly treated despite its high economic and social costs. Though previous work has examined how patient characteristics affect sleep medication prescriptions, the role of physician characteristics that influence this clinical decision remains unclear. We sought to understand patient and physician factors that influence sleep medication prescribing patterns by analyzing Electronic Medical Records (EMRs) including the narrative clinical notes as well as codified data. Zolpidem and trazodone were the most widely prescribed initial sleep medication in a cohort of 1,105 patients. Some providers showed a historical preference for one medication, which was highly predictive of their future prescribing behavior. Using a predictive model (AUC = 0.77), physician preference largely determined which medication a patient received (OR = 3.13 p = 3 × 10-37). In addition to the dominant effect of empirically determined physician preference, discussion of depression in a patient’s note was found to have a statistically significant association with receiving a prescription for trazodone (OR = 1.38, p = 0.04). EMR data can yield insights into physician prescribing behavior based on real-world physician-patient interactions.

  7. Medical and Dental Patient Issues

    Science.gov (United States)

    ... A RadiationAnswers.org Ask the Experts Medical and Dental Patient Issues What's My Risk? The risks of ... developed by our topic editors for this category: Dental-Patient Issues Medical CT Reference Books and Articles ...

  8. Self-reported stressors among patients with Exhaustion Disorder: an exploratory study of patient records

    Science.gov (United States)

    2014-01-01

    Background Several researchers imply that both work-related and non-work-related stress exposure are likely to contribute to stress-related mental illness. Yet empirical studies investigating both domains seem to be limited, particularly in a clinical population. The purpose of this study was to a) explore which stressors (non-work and work-related) are reported as important for the onset of illness by patients seeking medical care for stress-related exhaustion and b) explore the prevalence of each stressor and examine whether the pattern differs between men and women. Methods This is an exploratory mixed method study, comprising patients at a specialist outpatient stress clinic. Information from medical records of 20 patients was initially used in a first qualitative step to construct the instrument, using a combination of a conventional content analysis and a directed content analysis. In the second phase patient records from 50 men and 50 women were selected and coded in accordance with the coding instrument. Frequency statistics were calculated for all stressors. Results A total of 24 categories of stressors (11 related to work and 13 related to private life) were identified in the first qualitative step. A median of four stressors, usually both work and non-work-related was reported by the patients. The most common stressors were 1) quantitative demands at work, 2) private relational conflicts and 3) emotional demands at work. Conclusions Work demands are, by far, the most prevalent stressor, followed by relational problems in private life. The pattern was similar for women and men, with a slight difference in the distribution between work and non-work stressors. Men and women also show similar patterns when comparing the occurrence of each stressor. Slight differences were seen, in particular with regard to managerial responsibility that was reported by 6% of the women compared to 36% of the men. One important practical implication of this study is that

  9. 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.

  10. 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

    BACKGROUND: Data from hospital-based registers and medical records offer valuable sources of information for clinical and epidemiological research purposes. However, conducting high-quality epidemiological research requires valid and complete data sources. OBJECTIVE: To assess completeness...... 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...... Database therefore offers a valuable source for examining clinical, administrative, and research questions....

  11. Spirometry in Greenland: a cross-sectional study on patients treated with medication targeting obstructive pulmonary disease.

    Science.gov (United States)

    Nielsen, Lasse Overballe; Olsen, Sequssuna; Jarbøl, Dorte Ejg; Pedersen, Michael Lynge

    2016-01-01

    Chronic obstructive pulmonary disease (COPD) is globally increasing in frequency and is expected to be the third largest cause of death by 2020. Smoking is the main risk factor of developing COPD. In Greenland, more than half of the adult population are daily smokers, and COPD may be common. International guidelines recommend the usage of spirometry as a golden standard for diagnosing COPD. The current number of spirometries performed among patients treated with medication targeting obstructive pulmonary disease in Greenland remains unexplored. To estimate the prevalence of patients aged 50 years or above treated with medication targeting obstructive pulmonary disease and the extent to which spirometry was performed among them within 2 years. An observational, cross-sectional study based on the review of data obtained from electronic medical records in Greenland was performed. The inclusion criterion was that patients must have been permanent residents aged 50 years or above who had medication targeting obstructive pulmonary disease prescribed within a period of 15 months prior to data extraction. A full review of electronic patient records was done on each of the identified users of medication targeting obstructive pulmonary disease. Information on age, gender, town and spirometry was registered for each patient within the period from October 2013 to October 2015. The prevalence of patients treated with medication targeting obstructive pulmonary disease aged 50 years or above was 7.9%. Of those, 34.8% had spirometry performed within 2 years and 50% had a forced expiratory volume (1 sec)/ forced vital capacity (FEV1/FVC) under 70% indicating obstructive pulmonary disease. The use of medication targeting obstructive pulmonary disease among patients over 50 years old is common in Greenland. About one third of the patients had a spirometry performed within 2 years. To further increase spirometry performance, it is recommended to explore possible barriers in health

  12. Automated patient and medication payment method for clinical trials

    Directory of Open Access Journals (Sweden)

    Yawn BP

    2013-01-01

    Full Text Available Barbara P Yawn,1 Suzanne Madison,1 Susan Bertram,1 Wilson D Pace,2 Anne Fuhlbrigge,3 Elliot Israel,3 Dawn Littlefield,1 Margary Kurland,1 Michael E Wechsler41Olmsted Medical Center, Department of Research, Rochester, MN, 2UCDHSC, Department of Family Medicine, University of Colorado Health Science Centre, Aurora, CO, 3Brigham and Women's Hospital, Pulmonary and Critical Care Division, Boston, MA, 4National Jewish Medical Center, Division of Pulmonology, Denver, CO, USABackground: Published reports and studies related to patient compensation for clinical trials focus primarily on the ethical issues related to appropriate amounts to reimburse for patient's time and risk burden. Little has been published regarding the method of payment for patient participation. As clinical trials move into widely dispersed community practices and more complex designs, the method of payment also becomes more complex. Here we review the decision process and payment method selected for a primary care-based randomized clinical trial of asthma management in Black Americans.Methods: The method selected is a credit card system designed specifically for clinical trials that allows both fixed and variable real-time payments. We operationalized the study design by providing each patient with two cards, one for reimbursement for study visits and one for payment of medication costs directly to the pharmacies.Results: Of the 1015 patients enrolled, only two refused use of the ClinCard, requesting cash payments for visits and only rarely a weekend or fill-in pharmacist refused to use the card system for payment directly to the pharmacy. Overall, the system has been well accepted by patients and local study teams. The ClinCard administrative system facilitates the fiscal accounting and medication adherence record-keeping by the central teams. Monthly fees are modest, and all 12 study institutional review boards approved use of the system without concern for patient

  13. Electronic health record use, intensity of hospital care, and patient outcomes.

    Science.gov (United States)

    Blecker, Saul; Goldfeld, Keith; Park, Naeun; Shine, Daniel; Austrian, Jonathan S; Braithwaite, R Scott; Radford, Martha J; Gourevitch, Marc N

    2014-03-01

    Previous studies have suggested that weekend hospital care is inferior to weekday care and that this difference may be related to diminished care intensity. The purpose of this study was to determine whether a metric for measuring intensity of hospital care based on use of the electronic health record was associated with patient-level outcomes. We performed a cohort study of hospitalizations at an academic medical center. Intensity of care was defined as the hourly number of provider accessions of the electronic health record, termed "electronic health record interactions." Hospitalizations were categorized on the basis of the mean difference in electronic health record interactions between the first Friday and the first Saturday of hospitalization. We used regression models to determine the association of these categories with patient outcomes after adjusting for covariates. Electronic health record interactions decreased from Friday to Saturday in 77% of the 9051 hospitalizations included in the study. Compared with hospitalizations with no change in Friday to Saturday electronic health record interactions, the relative lengths of stay for hospitalizations with a small, moderate, and large decrease in electronic health record interactions were 1.05 (95% confidence interval [CI], 1.00-1.10), 1.11 (95% CI, 1.05-1.17), and 1.25 (95% CI, 1.15-1.35), respectively. Although a large decrease in electronic health record interactions was associated with in-hospital mortality, these findings were not significant after risk adjustment (odds ratio 1.74, 95% CI, 0.93-3.25). Intensity of inpatient care, measured by electronic health record interactions, significantly diminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals should consider monitoring and correcting temporal fluctuations in care intensity. Copyright © 2014 Elsevier Inc. All rights reserved.

  14. Instant availability of patient records, but diminished availability of patient information: A multi-method study of GP's use of electronic patient records

    Directory of Open Access Journals (Sweden)

    Grimsmo Anders

    2008-03-01

    Full Text Available Abstract Background In spite of succesful adoption of electronic patient records (EPR by Norwegian GPs, what constitutes the actual benefits and effects of the use of EPRs in the perspective of the GPs and patients has not been fully characterized. We wanted to study primary care physicians' use of electronic patient record (EPR systems in terms of use of different EPR functions and the time spent on using the records, as well as the potential effects of EPR systems on the clinician-patient relationship. Methods A combined qualitative and quantitative study that uses data collected from focus groups, observations of primary care encounters and a questionnaire survey of a random sample of general practitioners to describe their use of EPR in primary care. Results The overall availability of individual patient records had improved, but the availability of the information within each EPR was not satisfactory. GPs' use of EPRs were efficient and comprehensive, but have resulted in transfer of administrative work from secretaries to physicians. We found no indications of disturbance of the clinician-patient relationship by use of computers in this study. Conclusion Although GPs are generally satisfied with their EPRs systems, there are still unmet needs and functionality to be covered. It is urgent to find methods that can make a better representation of information in large patient records as well as prevent EPRs from contributing to increased administrative workload of physicians.

  15. Patient-directed Internet-based Medical Image Exchange: Experience from an Initial Multicenter Implementation.

    Science.gov (United States)

    Greco, Giampaolo; Patel, Anand S; Lewis, Sara C; Shi, Wei; Rasul, Rehana; Torosyan, Mary; Erickson, Bradley J; Hiremath, Atheeth; Moskowitz, Alan J; Tellis, Wyatt M; Siegel, Eliot L; Arenson, Ronald L; Mendelson, David S

    2016-02-01

    Inefficient transfer of personal health records among providers negatively impacts quality of health care and increases cost. This multicenter study evaluates the implementation of the first Internet-based image-sharing system that gives patients ownership and control of their imaging exams, including assessment of patient satisfaction. Patients receiving any medical imaging exams in four academic centers were eligible to have images uploaded into an online, Internet-based personal health record. Satisfaction surveys were provided during recruitment with questions on ease of use, privacy and security, and timeliness of access to images. Responses were rated on a five-point scale and compared using logistic regression and McNemar's test. A total of 2562 patients enrolled from July 2012 to August 2013. The median number of imaging exams uploaded per patient was 5. Most commonly, exams were plain X-rays (34.7%), computed tomography (25.7%), and magnetic resonance imaging (16.1%). Of 502 (19.6%) patient surveys returned, 448 indicated the method of image sharing (Internet, compact discs [CDs], both, other). Nearly all patients (96.5%) responded favorably to having direct access to images, and 78% reported viewing their medical images independently. There was no difference between Internet and CD users in satisfaction with privacy and security and timeliness of access to medical images. A greater percentage of Internet users compared to CD users reported access without difficulty (88.3% vs. 77.5%, P Internet-based image-sharing system is feasible and surpasses the use of CDs with respect to accessibility of imaging exams while generating similar satisfaction with respect to privacy. Copyright © 2015 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

  16. Evaluating hospital information systems from the point of view of the medical records section users in Medical-Educational Hospitals of Kermanshah 2014.

    Science.gov (United States)

    Rostami, S; Sarmad, A; Mohammadi, M; Cheleie, M; Amiri, S; Zardoei Golanbary, S H

    2015-01-01

    Evaluating hospital information systems leads to the improvement and devotion based on the users' needs, especially the medical records section users in hospitals, which are in contact with this system from the moment the patient enters the hospital until his/ her release and after that. The present research aimed to evaluate the hospital information systems from the point of view of the medical record section employees. Materials and method : The current research was applicative-descriptive analytical and the research society included 70 users of the medical history section in the educational-medical centers of Kermanshah city. The data-gathering tool was the 10th part of 9241/ 10 Isometric standard questionnaire of evaluating hospital information systems, with 75 specific questions in 7 bases, with the five spectra Likertt scale, its conceptual admissibility being confirmed in previous researches. 22 SPSS statistical software analyzed its permanency in the present study, which was also confirmed by Cronbach's's alpha test, which equaled to 0.89, and the data. Findings : The highest level of the employees' satisfaction, based on gained scores median, was respectively the incompatibility with the users' expectations, measuring 3.55, self-description measuring 3.54 and controllability - 3.51, which in total presented the average scores of 3.39, the lowest level of satisfaction being related to useful learning , whose value was 3.19. Discussion and conclusion : Hospital information systems' users believe that it is more desirable that the existing systems are based on the measures and consider them proper for making them non-governmental and useful for undesired learning. Considering the long distance of the existing information systems with the desired performance, it is essential that "these systems pay more attention to a more complete and deeper recognition and awareness of users' opinions and requirements in their road. The movement and development is to

  17. Barriers and facilitators of medication reconciliation processes for recently discharged patients from community pharmacists' perspectives.

    Science.gov (United States)

    Kennelty, Korey A; Chewning, Betty; Wise, Meg; Kind, Amy; Roberts, Tonya; Kreling, David

    2015-01-01

    Community pharmacists play a vital part in reconciling medications for patients transitioning from hospital to community care, yet their roles have not been fully examined in the extant literature. The objectives of this study were to: 1) examine the barriers and facilitators community pharmacists face when reconciling medications for recently discharged patients; and 2) identify pharmacists' preferred content and modes of information transfer regarding updated medication information for recently discharged patients. Community pharmacists were purposively and conveniently sampled from the Wisconsin (U.S. state) pharmacist-based research network, Pharmacy Practice Enhancement and Action Research Link (PEARL Rx). Community pharmacists were interviewed face-to-face, and transcriptions from audio recordings were analyzed using directed content analysis. The Theory of Planned Behavior (TPB) guided the development of questions for the semi-structured interviews. Interviewed community pharmacists (N = 10) described the medication reconciliation process to be difficult and time-consuming for recently discharged patients. In the context of the TPB, more barriers than facilitators of reconciling medications were revealed. Themes were categorized as organizational and individual-level themes. Major organizational-level factors affecting the medication reconciliation process included: pharmacy resources, discharge communication, and hospital resources. Major individual-level factors affecting the medication reconciliation process included: pharmacists' perceived responsibility, relationships, patient perception of pharmacist, and patient characteristics. Interviewed pharmacists consistently responded that several pieces of information items would be helpful when reconciling medications for recently discharged patients, including the hospital medication discharge list and stop-orders for discontinued medications. The TPB was useful for identifying barriers and facilitators of

  18. 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.

  19. Air medical transport of cardiac patients.

    Science.gov (United States)

    Essebag, Vidal; Halabi, Abdul R; Churchill-Smith, Michael; Lutchmedial, Sohrab

    2003-11-01

    The air medical transport of cardiac patients is a rapidly expanding practice. For various medical, social, and economic indications, patients are being flown longer distances at commercial altitudes, including international and intercontinental flights. There are data supporting the use of short-distance helicopter flights early in the course of a cardiac event for patients needing emergent transfer for percutaneous coronary intervention or aortocoronary bypass. When considering elective long-distance air medical transport of cardiac patients for social or economic reasons, it is necessary to weigh the benefits against the potential risks of flight. A few recent studies suggest that long-distance air medical transport is safe under certain circumstances. Current guidelines for air travel after myocardial infarction do not address the use of medical escorts or air ambulances equipped with intensive care facilities. Further research using larger prospective studies is needed to better define criteria for safe long-distance air medical transport of cardiac patients.

  20. Medical terminology in online patient-patient communication: evidence of high health literacy?

    Science.gov (United States)

    Fage-Butler, Antoinette M; Nisbeth Jensen, Matilde

    2016-06-01

    Health communication research and guidelines often recommend that medical terminology be avoided when communicating with patients due to their limited understanding of medical terms. However, growing numbers of e-patients use the Internet to equip themselves with specialized biomedical knowledge that is couched in medical terms, which they then share on participatory media, such as online patient forums. Given possible discrepancies between preconceptions about the kind of language that patients can understand and the terms they may actually know and use, the purpose of this paper was to investigate medical terminology used by patients in online patient forums. Using data from online patient-patient communication where patients communicate with each other without expert moderation or intervention, we coded two data samples from two online patient forums dedicated to thyroid issues. Previous definitions of medical terms (dichotomized into technical and semi-technical) proved too rudimentary to encapsulate the types of medical terms the patients used. Therefore, using an inductive approach, we developed an analytical framework consisting of five categories of medical terms: dictionary-defined medical terms, co-text-defined medical terms, medical initialisms, medication brand names and colloquial technical terms. The patients in our data set used many medical terms from all of these categories. Our findings suggest the value of a situated, condition-specific approach to health literacy that recognizes the vertical kind of knowledge that patients with chronic diseases may have. We make cautious recommendations for clinical practice, arguing for an adaptive approach to medical terminology use with patients. © 2015 The Authors. Health Expectations Published by John Wiley & Sons Ltd.

  1. Phenotyping for patient safety: algorithm development for electronic health record based automated adverse event and medical error detection in neonatal intensive care.

    Science.gov (United States)

    Li, Qi; Melton, Kristin; Lingren, Todd; Kirkendall, Eric S; Hall, Eric; Zhai, Haijun; Ni, Yizhao; Kaiser, Megan; Stoutenborough, Laura; Solti, Imre

    2014-01-01

    Although electronic health records (EHRs) have the potential to provide a foundation for quality and safety algorithms, few studies have measured their impact on automated adverse event (AE) and medical error (ME) detection within the neonatal intensive care unit (NICU) environment. This paper presents two phenotyping AE and ME detection algorithms (ie, IV infiltrations, narcotic medication oversedation and dosing errors) and describes manual annotation of airway management and medication/fluid AEs from NICU EHRs. From 753 NICU patient EHRs from 2011, we developed two automatic AE/ME detection algorithms, and manually annotated 11 classes of AEs in 3263 clinical notes. Performance of the automatic AE/ME detection algorithms was compared to trigger tool and voluntary incident reporting results. AEs in clinical notes were double annotated and consensus achieved under neonatologist supervision. Sensitivity, positive predictive value (PPV), and specificity are reported. Twelve severe IV infiltrates were detected. The algorithm identified one more infiltrate than the trigger tool and eight more than incident reporting. One narcotic oversedation was detected demonstrating 100% agreement with the trigger tool. Additionally, 17 narcotic medication MEs were detected, an increase of 16 cases over voluntary incident reporting. Automated AE/ME detection algorithms provide higher sensitivity and PPV than currently used trigger tools or voluntary incident-reporting systems, including identification of potential dosing and frequency errors that current methods are unequipped to detect. 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.

  2. Medical History of Elderly Patients in the Emergency Setting: Not an Easy Point-of-Care Diagnostic Marker

    Directory of Open Access Journals (Sweden)

    Tobias Lindner

    2015-01-01

    Full Text Available Background. Medical histories are a crucially important diagnostic tool. Elderly patients represent a large and increasing group of emergency patients. Due to cognitive deficits, taking a reliable medical history in this patient group can be difficult. We sought to evaluate the medical history-taking in emergency patients above 75 years of age with respect to duration and completeness. Methods. Anonymous data of consecutive patients were recorded. Times for the defined basic medical history-taking were documented, as were the availability of other sources and times to assess these. Results. Data of 104 patients were included in the analysis. In a quarter of patients (25%, n=26 no complete basic medical history could be obtained. In the group of patients where complete data could be gathered, only 16 patients were able to provide all necessary information on their own. Including other sources like relatives or GPs prolonged the time until complete medical history from 7.3 minutes (patient only to 26.4 (+relatives and 56.3 (+GP minutes. Conclusions. Medical histories are important diagnostic tools in the emergency setting and are prolonged in the elderly, especially if additional documentation and third parties need to be involved. New technologies like emergency medical cards might help to improve the availability of important patient data but implementation of these technologies is costly and faces data protection issues.

  3. Open source electronic health record and patient data management system for intensive care.

    Science.gov (United States)

    Massaut, Jacques; Reper, Pascal

    2008-01-01

    In Intensive Care Units, the amount of data to be processed for patients care, the turn over of the patients, the necessity for reliability and for review processes indicate the use of Patient Data Management Systems (PDMS) and electronic health records (EHR). To respond to the needs of an Intensive Care Unit and not to be locked with proprietary software, we developed a PDMS and EHR based on open source software and components. The software was designed as a client-server architecture running on the Linux operating system and powered by the PostgreSQL data base system. The client software was developed in C using GTK interface library. The application offers to the users the following functions: medical notes captures, observations and treatments, nursing charts with administration of medications, scoring systems for classification, and possibilities to encode medical activities for billing processes. Since his deployment in February 2004, the PDMS was used to care more than three thousands patients with the expected software reliability and facilitated data management and review processes. Communications with other medical software were not developed from the start, and are realized by the use of the Mirth HL7 communication engine. Further upgrade of the system will include multi-platform support, use of typed language with static analysis, and configurable interface. The developed system based on open source software components was able to respond to the medical needs of the local ICU environment. The use of OSS for development allowed us to customize the software to the preexisting organization and contributed to the acceptability of the whole system.

  4. Geriatric syndromes are potential determinants of the medication adherence status in prevalent dialysis patients

    Directory of Open Access Journals (Sweden)

    Chia-Ter Chao

    2016-06-01

    Full Text Available Background. Geriatric syndromes (GS exhibit high prevalence in patients with end-stage renal disease (ESRD under chronic dialysis irrespective of age. We sought to determine whether GS influences medication adherence in ESRD patients. Methods. A prospective cohort of chronic dialysis patients was assembled. The presence of GS components, including frailty/prefrailty, polypharmacy, and malnutrition, were ascertained through a validated questionnaire, electronic records and chart abstraction, and laboratory tests. The severity of medication non-adherence was defined using the eight-item Morisky Medication Adherence Scale (MMAS. Multiple logistic regression analysis was performed targeting MMAS results and incorporating relevant clinical features and GS. Results. The prevalence of frailty/pre-frailty, polypharmacy, and hypoalbuminemia/ malnutrition among the enrolled participants was 66.7%, 94%, and 14%, respectively. The average MMAS scores in these dialysis patients were 2 ± 1.7 (range, 0–6, with only 15.7% exhibiting high medication adherence. Multiple regression analyses showed that the absence of frailty/pre-frailty (P = 0.01 were significantly associated with poorer medication adherence, while the presence of polypharmacy (P = 0.02 and lower serum albumin, a potential sign of malnutrition (P = 0.03, were associated with poor adherence in another model. Conclusion. This study is among the very few reports addressing GS and medication adherence, especially in ESRD patients. Interventions targeting frailty, polypharmacy, and malnutrition might potentially improve the medication non-adherence and symptom control in these pill-burdened patients.

  5. An 'Honest Broker' mechanism to maintain privacy for patient care and academic medical research.

    Science.gov (United States)

    Boyd, Andrew D; Hosner, Charlie; Hunscher, Dale A; Athey, Brian D; Clauw, Daniel J; Green, Lee A

    2007-01-01

    From the Hippocratic Oath to the World Medical Association's Declaration of Geneva, physicians have sworn to protect patients' privacy. However, as systems move to more integrated architectures, protecting this medical data becomes more of a challenge. The increase in complexity of IT environments, the aggregation of data, and the desire of other entities to access this data, often 24 h/day x 7 day/week x 365 day/year, is putting serious strains on our ability to maintain its security. This problem cuts across all electronic record sources from patient care records to academic medical research records. In order to address this issue, we are rethinking the way we store, transmit, process, access, and federate patient data from clinical and research applications. Our groups at the University of Michigan are developing a system called the "Honest Broker" to help manage this problem. The Honest Broker will offload the burden of housing identifiable data elements of protected health information (PHI) (e.g., name and address) as well as manage data transfer between clinical and research systems. Lab results and other non-identifiable data will be stored in separate systems with either a research study ID or clinical ID number. This two-component architecture increases the burden on attackers who now need to compromise two systems, one of which is seriously hardened, in order to match health data with a patient's actual identity. While no security system is truly intrusion-proof, this architecture provides a high security choke point reducing the likelihood of a breach. By redesigning the method of integrating clinical care and research, we have enabled projects that would be cost prohibitive to conduct otherwise. The scalability of this mechanism is dependant on nature of the heterogenous nature of the clinical systems serving patients.

  6. Automated Detection of Sepsis Using Electronic Medical Record Data: A Systematic Review.

    Science.gov (United States)

    Despins, Laurel A

    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.

  7. Disparities in the Use of Internet and Telephone Medication Refills among Linguistically Diverse Patients.

    Science.gov (United States)

    Moreno, Gerardo; Lin, Elizabeth H; Chang, Eva; Johnson, Ron L; Berthoud, Heidi; Solomon, Cam C; Morales, Leo S

    2016-03-01

    Health systems are increasingly implementing remote telephone and Internet refill systems to enhance patient access to medication refills. Remote refill systems may provide an effective approach for improving medication non-adherence, but more research is needed among patients with limited English proficiency with poor access to remote refill systems. To compare the use of remote medication refill systems among limited-English-proficiency (LEP) and English-proficient (EP) patients with chronic conditions. Cross-sectional survey in six languages/dialects (English, Cantonese, Mandarin, Korean, Vietnamese, and Spanish) of 509 adults with diabetes, hypertension, or hyperlipidemia. Primary study outcomes were self-reported use of 1) Internet refills, 2) telephone refills, and 3) any remote refill system. LEP was measured by patient self-identification of a primary language other than English and a claims record of use of an interpreter. Other measures were age, gender, education, years in the U.S., insurance, health status, chronic conditions, and number of prescribed medications. Analyses included multivariable logistic regression weighted for survey non-response. Overall, 33.1 % of patients refilled their medications by telephone and 31.6 % by Internet. Among LEP patients (n = 328), 31.5 % refilled by telephone and 21.2 % by Internet, compared with 36.7 % by telephone and 52.7 % by Internet among EP patients (n = 181). Internet refill by language groups were as follows: English (52.7 %), Cantonese (34.9 %), Mandarin (17.4 %), Korean (16.7 %), Vietnamese (24.4 %), and Spanish (12.6 %). Compared to EP patients, LEP patients had lower use of any remote refill system (adjusted odds ratio [AOR] 0.18; p use any remote medication refill system. Increased reliance on current systems for remote medication refills may increase disparities in health outcomes affecting LEP patients with poor access to telephone and Internet medication refills.

  8. Scalable decision support at the point of care: a substitutable electronic health record app for monitoring medication adherence.

    Science.gov (United States)

    Bosl, William; Mandel, Joshua; Jonikas, Magdalena; Ramoni, Rachel Badovinac; Kohane, Isaac S; Mandl, Kenneth D

    2013-07-22

    Non-adherence to prescribed medications is a serious health problem in the United States, costing an estimated $100 billion per year. While poor adherence should be addressable with point of care health information technology, integrating new solutions with existing electronic health records (EHR) systems require customization within each organization, which is difficult because of the monolithic software design of most EHR products. The objective of this study was to create a published algorithm for predicting medication adherence problems easily accessible at the point of care through a Web application that runs on the Substitutable Medical Apps, Reusuable Technologies (SMART) platform. The SMART platform is an emerging framework that enables EHR systems to behave as "iPhone like platforms" by exhibiting an application programming interface for easy addition and deletion of third party apps. The app is presented as a point of care solution to monitoring medication adherence as well as a sufficiently general, modular application that may serve as an example and template for other SMART apps. The widely used, open source Django framework was used together with the SMART platform to create the interoperable components of this app. Django uses Python as its core programming language. This allows statistical and mathematical modules to be created from a large array of Python numerical libraries and assembled together with the core app to create flexible and sophisticated EHR functionality. Algorithms that predict individual adherence are derived from a retrospective study of dispensed medication claims from a large private insurance plan. Patients' prescription fill information is accessed through the SMART framework and the embedded algorithms compute adherence information, including predicted adherence one year after the first prescription fill. Open source graphing software is used to display patient medication information and the results of statistical prediction

  9. Medical Guidelines Presentation and Comparing with Electronic Health Record

    Czech Academy of Sciences Publication Activity Database

    Veselý, Arnošt; Zvárová, Jana; Peleška, Jan; Buchtela, David; Anger, Z.

    2006-01-01

    Roč. 75, č. 3-4 (2006), s. 240-245 ISSN 1386-5056 R&D Projects: GA AV ČR 1ET200300413 Institutional research plan: CEZ:AV0Z10300504 Keywords : medical guidelines * electronic health record * GLIF model * reminder facility Subject RIV: IN - Informatics, Computer Science Impact factor: 1.726, year: 2006

  10. Improving patient-centered communication while using an electronic health record: Report from a curriculum evaluation.

    Science.gov (United States)

    Fogarty, Colleen T; Winters, Paul; Farah, Subrina

    2016-05-01

    Researchers and clinicians are concerned about the impact of electronic health record use and patient-centered communication. Training about patient-centered clinical communication skills with the electronic health record may help clinicians adapt and remain patient-centered. We developed an interactive workshop eliciting challenges and opportunities of working with the electronic health record in clinical practice, introduction of specific patient-centered behaviors and mindful practice techniques, and video demonstrating contrasts in common behavior and "better practices." One hundred thirty-nine resident physicians and faculty supervisors in five residency training programs at the University of Rochester Medical Center participated in the workshops. Participants were asked to complete an 11-item survey of behaviors related to their use of the electronic health record prior to training and after attending training. We used paired t-tests to assess changes in self-reported behavior from pre-intervention to post-intervention. We trained 139 clinicians in the workshops; 110 participants completed the baseline assessment and 39 completed both the baseline and post-intervention assessment. Data from post-curriculum respondents found a statistically significant increase in "I told the patient when turning my attention from the patient to the computer," from 60% of the time prior to the training to 70% of the time after. Data from our program evaluation demonstrated improvement in one communication behavior. Sample size limited the detection of other changes; further research should investigate effective training techniques for patient-centered communication while using the electronic health record. © The Author(s) 2016.

  11. 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.

  12. Electronic Health Records: An Enhanced Security Paradigm to Preserve Patient's Privacy

    Science.gov (United States)

    Slamanig, Daniel; Stingl, Christian

    In recent years, demographic change and increasing treatment costs demand the adoption of more cost efficient, highly qualitative and integrated health care processes. The rapid growth and availability of the Internet facilitate the development of eHealth services and especially of electronic health records (EHRs) which are promising solutions to meet the aforementioned requirements. Considering actual web-based EHR systems, patient-centric and patient moderated approaches are widely deployed. Besides, there is an emerging market of so called personal health record platforms, e.g. Google Health. Both concepts provide a central and web-based access to highly sensitive medical data. Additionally, the fact that these systems may be hosted by not fully trustworthy providers necessitates to thoroughly consider privacy issues. In this paper we define security and privacy objectives that play an important role in context of web-based EHRs. Furthermore, we discuss deployed solutions as well as concepts proposed in the literature with respect to this objectives and point out several weaknesses. Finally, we introduce a system which overcomes the drawbacks of existing solutions by considering an holistic approach to preserve patient's privacy and discuss the applied methods.

  13. [Who decides what data should be recorded in the medical history in relation to the biological origin?

    Science.gov (United States)

    Gallego Riestra, Sergio; Riaño Galán, Isolina

    2018-02-01

    There is an increasing request by patients or their representatives not to have some data registered in their clinical history or if such data exists to be deleted. Without doubt, this is so because such clinical data is accessed by various professionals who in most cases are not directly involved in caring for such patients. On the other hand, such data is copied and iteratively and unnecessary reproduced in various discharge reports and others forms. The problem arises when such controversial data refer to particularly sensitive clinical aspects such as assisted reproduction techniques, which invades personal and family privacy. Therefore, the question is who determines what data should be recorded in the medical records and according to what criteria should be taken that decision? Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

  14. A color display device recording X ray spectra, especially intended for medical radiography

    International Nuclear Information System (INIS)

    Boulch, J.-M.

    1975-01-01

    Said invention relates to a color display recording device for X ray spectra intended for medical radiography. The video signal of the X ray camera receiving the radiation having passed through the patient is amplified and transformed into a color coding according to the energy spectrum received by the camera. In a first version, the energy spectrum from the camera gives directly an image on the color tube. In a second version the energy spectrum, after having been transformed into digital signals, is first sent into a memory, then into a computer used as a spectrum analyzer, and finally into the color display device [fr

  15. Methods of defining hypertension in electronic medical records: validation against national survey data.

    Science.gov (United States)

    Peng, Mingkai; Chen, Guanmin; Kaplan, Gilaad G; Lix, Lisa M; Drummond, Neil; Lucyk, Kelsey; Garies, Stephanie; Lowerison, Mark; Weibe, Samuel; Quan, Hude

    2016-09-01

    Electronic medical records (EMR) can be a cost-effective source for hypertension surveillance. However, diagnosis of hypertension in EMR is commonly under-coded and warrants the needs to review blood pressure and antihypertensive drugs for hypertension case identification. We included all the patients actively registered in The Health Improvement Network (THIN) database, UK, on 31 December 2011. Three case definitions using diagnosis code, antihypertensive drug prescriptions and abnormal blood pressure, respectively, were used to identify hypertension patients. We compared the prevalence and treatment rate of hypertension in THIN with results from Health Survey for England (HSE) in 2011. Compared with prevalence reported by HSE (29.7%), the use of diagnosis code alone (14.0%) underestimated hypertension prevalence. The use of any of the definitions (38.4%) or combination of antihypertensive drug prescriptions and abnormal blood pressure (38.4%) had higher prevalence than HSE. The use of diagnosis code or two abnormal blood pressure records with a 2-year period (31.1%) had similar prevalence and treatment rate of hypertension with HSE. Different definitions should be used for different study purposes. The definition of 'diagnosis code or two abnormal blood pressure records with a 2-year period' could be used for hypertension surveillance in THIN. © The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  16. Validation of celiac disease diagnoses recorded in the Danish National Patient Register using duodenal biopsies, celiac disease-specific antibodies, and human leukocyte-antigen genotypes

    DEFF Research Database (Denmark)

    Dydensborg Sander, Stine; Størdal, Ketil; Plato Hansen, Tine

    2016-01-01

    PURPOSE: The purpose of this study was to validate the celiac disease diagnoses recorded in the Danish National Patient Register. To validate the diagnoses, we used information on duodenal biopsies from a national register of pathology reports (the Patobank) and information on celiac disease......-specific antibodies and human leukocyte antigen (HLA) genotypes obtained from patient medical records. PATIENTS AND METHODS: We included all the children who were born from 1995 to 2012 and who were registered as having celiac disease in the Danish National Patient Register. We reviewed all the pathology reports...... on duodenal biopsies in the Patobank and the information in the medical records on celiac disease-specific antibodies (ie, anti-tissue transglutaminase 2 IgA and IgG, endomysial antibodies IgA, and anti-deamidated gliadin peptide IgG) and HLA genotypes. RESULTS: We identified 2,247 children who were...

  17. Association of Social Support and Medication Adherence in Chinese Patients with Type 2 Diabetes Mellitus.

    Science.gov (United States)

    Gu, Linni; Wu, Shaomin; Zhao, Shuliang; Zhou, Huixuan; Zhang, Shengfa; Gao, Min; Qu, Zhiyong; Zhang, Weijun; Tian, Donghua

    2017-12-06

    The prevalence of diabetes is steadily increasing in China. When diabetes is uncontrolled, it generates dire consequences for health and well-being. Numerous studies have shown that health outcomes were associated with social support and medication adherence. Previous study confirmed that social support was associated with medication adherence in patients with heart failure, HIV diseases, and first-episode psychosis. However, the relationship between social support and medication adherence in patients with type 2 diabetes mellitus (T2DM) is remains unclear. This study aims to examine whether social support is associated with medication adherence in patients with T2DM. This study was conducted in the First Affiliated Hospital of the General Hospital of the People's Liberation Army (PLA). In Beijing, a systematic random sample of 412 patients with T2DM over 18 years was recruited at baseline, and demographic characteristics, clinical data and their assessment of social support were collected from medical records and self-reported questionnaires. 330 of these patients completed a self-report measure of medication adherence at the sixth month after baseline data collection. Regression analysis showed that social support presented a positive effect on medication adherence, additionally, support utilization and the subscale of social support exhibited a significantly strong influence on medication adherence in patients with T2DM. Although medication adherence was influenced by multiple factors, this finding confirmed that social support must be recognized as a core element in interventions aimed at improving in the management of patients with T2DM.

  18. Assessment of patient knowledge of diabetic goals, self-reported medication adherence, and goal attainment

    Directory of Open Access Journals (Sweden)

    Whitley HP

    2006-12-01

    Full Text Available Background: Medication adherence is an integral aspect of disease state management for patients with chronic illnesses, including diabetes mellitus. It has been hypothesized that patients with diabetes who have poor medication adherence may have less knowledge of overall therapeutic goals and may be less likely to attain these goals. Objective: The purpose of this study was to assess self-reported medication adherence, knowledge of therapeutic goals (hemoglobin A1C [A1C], low density lipoprotein cholesterol [LDL-C] and blood pressure [BP], and goal attainment in adult patients with diabetes. Methods: A survey was created to assess medication adherence, knowledge of therapeutic goals, and goal attainment for adult patients with diabetes followed at an internal medicine or a family medicine clinic. Surveys were self-administered prior to office visits. Additional data were collected from the electronic medical record. Statistical analysis was performed. Results: A total of 149 patients were enrolled. Knowledge of therapeutic goals was reported by 14%, 34%, and 18% of survived patients for LDL-C, BP, and A1C, respectively. Forty-six percent, 37%, and 40% of patients achieved LDL-C, BP, and A1C goals, respectively. Low prescribing of cholesterol-lowering medications was an interesting secondary finding; 36% of patients not at LDL-C goal had not been prescribed a medication targeted to lower cholesterol. Forty-eight percent of patients were medication non-adherent; most frequently reported reasons for non-adherence were forgot (34% and too expensive (14%. Patients at A1C goal were more adherent than patients not at goal (p=0.025. Conclusion: The majority did not reach goals and were unknowledgeable of goals; however, most were provided prescriptions to treat these parameters. Goal parameters should be revisited often amongst multidisciplinary team members with frequent and open communications. Additionally, it is imperative that practitioners discuss

  19. Type D Personality Predicts Poor Medication Adherence in Patients with Heart Failure in the USA

    Science.gov (United States)

    Wu, Jia-Rong; Moser, Debra K.

    2015-01-01

    Background Type D (distressed) personality and medication nonadherence have been associated with poor health outcomes. Type D personality is associated with poor medication adherence in patients with coronary artery disease. However, the relationship between type D personality and medication adherence in patients with heart failure (HF) remains unknown. Purpose Therefore, the goal of this study was to examine the association between type D personality and medication adherence in patients with HF. Method This was a sub-analysis of baseline data from a randomized controlled trial with 84 patients with HF in the USA. Demographic, clinical, and psychological data were collected at baseline by interview, questionnaires, and medical record review. Type D personality was assessed using the Type D Personality Scale (DS14). Medication adherence was measured using both objective (Medication Event Monitoring System, MEMS) and self-reported (Morisky Medication Adherence Scale, MMAS-4) measures. Patients started medication adherence monitoring with the MEMS bottle at baseline and is used continuously for a month. Multiple regressions were used to explore the relationships between type D personality and medication adherence while adjusting for demographic, clinical, and psychological factors. Results Patients with type D personality were more likely to have poor medication adherence. Type D personality was associated with medication adherence before and after adjusting for covariates when it was analyzed as a categorical variable. However, type D personality was not associated with medication adherence when analyzed as a dimensional construct. Negative affectivity, a component of type D personality, was associated with medication adherence. Conclusion As a dimensional construct, type D personality may not reflect the components of the personality associated with poor outcomes. Negative affectivity was associated with medication adherence in patients with HF. Interventions aiming

  20. Recognition of anxiety disorders by family physicians after rigorous medical record case extraction Results of the Netherlands Study of Depression and Anxiety

    NARCIS (Netherlands)

    Janssen, Evelien H. C.; van de Ven, Peter M.; Terluin, Berend; Verhaak, Peter F. M.; van Marwijk, Harm W. J.; Smolders, Mirrian; van der Meer, Klaas; Penninx, Brenda W. J. H.; van Hout, Hein P. J.

    2012-01-01

    Objective: Previous studies reported low and inconsistent rates of recognition of anxiety disorders by family physicians (FPs). Our objectives were to examine (a) which combination of indications within medical records most accurately reflects recognition of anxiety disorders and (b) whether patient

  1. Recognition of anxiety disorders by family physicians after rigorous medical record case extraction: results of the Netherlands Study of Depression and Anxiety.

    NARCIS (Netherlands)

    Janssen, E.H.C.; Ven, P.M. van de; Terluin, B.; Verhaak, P.F.M.; Marwijk, H.W.J. van; Smolders, M.; Meer, K. van der; Penninx, B.W.J.H.; Hout, H.P.J. van

    2012-01-01

    Objective: Previous studies reported low and inconsistent rates of recognition of anxiety disorders by family physicians (FPs). Our objectives were to examine (a) which combination of indications within medical records most accurately reflects recognition of anxiety disorders and (b) whether patient

  2. Joint development of evidence-based medical record by doctors and patients through integrated Chinese and Western medicine on digestive system diseases.

    Science.gov (United States)

    Li, Bo; Gao, Hong-yang; Gao, Rui; Zhao, Ying-pan; Li, Qing-na; Zhao, Yang; Tang, Xu-dong; Shang, Hong-cai

    2016-02-01

    Building the clinical therapeutic evaluation system by combing the evaluation given by doctors and patients can form a more comprehensive and objective evaluation system. A literature search on the practice of evidence-based evaluation was conducted in key biomedical databases, i.e. PubMed, Excerpt Medica Database, China Biology Medicine disc and China National Knowledge Infrastructure. However, no relevant study on the subjects of interest was identified. Therefore, drawing on the principles of narrative medicine and expert opinion from systems of Chinese medicine and Western medicine, we propose to develop and pilot-test a novel evidence-based medical record format that captures the perspectives of both patients and doctors in a clinical trial. Further, we seek to evaluate a strategic therapeutic approach that integrates the wisdom of Chinese medicine with the scientific basis of Western medicine in the treatment of digestive system disorders. Evaluation of therapeutic efficacy of remedies under the system of Chinese medicine is an imperative ongoing research. The present study intends to identify a novel approach to assess the synergistic benefits achievable from an integrated therapeutic approach combining Chinese and Western system of medicine to treat digestive system disorders.

  3. Prescription for antidepressant in reducing future alcohol-related readmission in patients suffering from depression and alcohol use disorder: a retrospective medical record review.

    Science.gov (United States)

    Chan, Patrick; Yomen, Katie; Turcios, Jennifer; Richman, Mark

    2015-12-21

    Patients suffering from major depressive disorder are more likely to suffer from alcohol use disorder. The data is inconclusive for the effectiveness of antidepressant treatment of patients suffering from both illnesses in regards to improving sobriety and reducing alcohol-related healthcare expenses such as hospitalizations. The objective of this study is to determine if a new prescription of an antidepressant upon inpatient discharge is associated with a reduction in the number of future acute alcohol-related hospital readmissions to the same institution in patients suffering from major depressive disorder and alcohol-use disorder. A retrospective, medical record review study was conducted at a publicly-supported hospital in Sylmar, CA. A query was performed for adult patients admitted between 1/1/2005-12/31/2013 who had ICD-9 codes for both alcohol-use disorder and depression. Index admission was the first hospitalization in which the patient was currently consuming alcohol and had depression as identified by physician documentation as a problem. Acute alcohol-related admissions were those for alcohol intoxication or withdrawal (indicating current alcohol use). Patients were excluded if they were receiving an antidepressant on index admission, depressive disorder with a prescription for an antidepressant is not associated with a reduction in future readmissions, nor significantly increase the number of days to readmission. The study does not support the concept of antidepressants in reducing acute alcohol-related readmissions.

  4. Integration of clinical research documentation in electronic health records.

    Science.gov (United States)

    Broach, Debra

    2015-04-01

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

  5. A Natural Language Processing System That Links Medical Terms in Electronic Health Record Notes to Lay Definitions: System Development Using Physician Reviews.

    Science.gov (United States)

    Chen, Jinying; Druhl, Emily; Polepalli Ramesh, Balaji; Houston, Thomas K; Brandt, Cynthia A; Zulman, Donna M; Vimalananda, Varsha G; Malkani, Samir; Yu, Hong

    2018-01-22

    Many health care systems now allow patients to access their electronic health record (EHR) notes online through patient portals. Medical jargon in EHR notes can confuse patients, which may interfere with potential benefits of patient access to EHR notes. The aim of this study was to develop and evaluate the usability and content quality of NoteAid, a Web-based natural language processing system that links medical terms in EHR notes to lay definitions, that is, definitions easily understood by lay people. NoteAid incorporates two core components: CoDeMed, a lexical resource of lay definitions for medical terms, and MedLink, a computational unit that links medical terms to lay definitions. We developed innovative computational methods, including an adapted distant supervision algorithm to prioritize medical terms important for EHR comprehension to facilitate the effort of building CoDeMed. Ten physician domain experts evaluated the user interface and content quality of NoteAid. The evaluation protocol included a cognitive walkthrough session and a postsession questionnaire. Physician feedback sessions were audio-recorded. We used standard content analysis methods to analyze qualitative data from these sessions. Physician feedback was mixed. Positive feedback on NoteAid included (1) Easy to use, (2) Good visual display, (3) Satisfactory system speed, and (4) Adequate lay definitions. Opportunities for improvement arising from evaluation sessions and feedback included (1) improving the display of definitions for partially matched terms, (2) including more medical terms in CoDeMed, (3) improving the handling of terms whose definitions vary depending on different contexts, and (4) standardizing the scope of definitions for medicines. On the basis of these results, we have improved NoteAid's user interface and a number of definitions, and added 4502 more definitions in CoDeMed. Physician evaluation yielded useful feedback for content validation and refinement of this

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

    Science.gov (United States)

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

  7. [Use of medical treatment data outside of the patient supply: best way pseudonymisation].

    Science.gov (United States)

    Schütze, B

    2012-04-01

    The use of data pending during the patient supply to research, quality assurance as also to education is desirable. However, this use is not allowed in every German federal land without approval of the patient. Just in the case of retrospective research an approval of the patient is often not to be received. For the use of medical routine data for the research the pseudonymisation is good therefore. Pseudonymisation is a procedure by which all person-related data within a data record is replaced by one artificial identifier. Therefore pseudonymisation facilitates the linking of medical data and the data identifying the patient only under certain, before defined and controllable conditions. Through that medical data can be passed on to third party without this third party being able to identify the person who the medical data belong to. Under consideration of the present possibilities of the information technology as also the available technical preparations for the use of the pseudonymisation and the advantages being inherent in the pseudonymisation the pseudonymisation represents the method of choice during the use of data of the patient supply to the research, quality assurance as well as education. © Georg Thieme Verlag KG Stuttgart · New York.

  8. Current patient and healthcare worker attitudes to eHealth and the personally controlled electronic health record in major hospitals.

    Science.gov (United States)

    Armani, R; Mitchell, L E; Allen-Graham, J; Heriot, N R; Kotsimbos, T; Wilson, J W

    2016-06-01

    The current health system in Australia is comprised of both electronic- and paper-based medical records. The Federal Government has approved funding for the development of an individual health identifier and a universally adopted online health repository. To determine attitudes and beliefs of patients and healthcare workers regarding the use of stored medical information and the personally controlled electronic health record (PCEHR) in selected major hospitals in Victoria. Qualitative survey of patients and healthcare workers (n = 600 each group) conducted during 2014 across five major hospitals in Melbourne to measure the awareness, attitudes and barriers to electronic health and the PCEHR. Of the patients, 93.3% support the concept of a shared electronic healthcare record, 33.7% were aware of the PCEHR and only 11% had registered. The majority of healthcare workers believed that the presence of a shared health record would result in an increased appropriateness of care and patient safety by reducing adverse drug events and improving the timeliness of care provided. However, only 46% of healthcare workers were aware of the PCEHR. This study provides a baseline evaluation of perceptions surrounding eHealth and PCHER in acute health services in five metropolitan centres. While there appears to be a readiness for adoption of these strategies for healthcare documentation, patients require motivation to register for the PCEHR, and healthcare workers require more information on the potential benefits to them to achieve more timely and efficient care. © 2016 Royal Australasian College of Physicians.

  9. Medication adherence in type 2 diabetes patients: study of patients ...

    African Journals Online (AJOL)

    Medication adherence in type 2 diabetes patients: study of patients in ... impact of medication adherence on the clinical outcomes of type 2 diabetes patients at ... the review of case notes of one-hundred and fifty two randomly selected patients.

  10. Patient satisfaction with medical care

    Directory of Open Access Journals (Sweden)

    M. A. Sadovoy

    2017-01-01

    Full Text Available Patients’ evaluation of medical care is becoming more and more important due to expanding patient-centered care. For this purpose a complex index of patient satisfaction with healthcare is used. This parameter reflects the correspondence of actual healthcare services to patient’s expectations that were formed under the influence of cultural, social, economic factors, and personal experience of each patient. Satisfaction is a subjective parameter, thus, a grade of satisfaction is barely connected with quality of healthcare services itself. Moreover, medical organizations should always take into account specific features of each patient, since they can have an influence on customer attitude to medical services.This article comprises the review of publications studying determinants of patient satisfaction. In the course of the study, we analyzed data received by research teams from different countries.According to the review, we made some conclusions. First, determinants of patient satisfaction with healthcare can be divided in two groups. The first group of factors includes patients’ characteristics such as age, gender, ethnical and cultural features. However, researches from different countries revealed that there is a difference in the importance of factors belonging to this group and their influence on satisfaction of certain patient cohorts. The second group includes factors that belong to the process of healthcare services delivery and its organization. Moreover, it was found that patient satisfaction level is changing in a waveform. Thus, medical organization should not only try to increase patient satisfaction level but also maintain it. AS a result, it necessary to monitor patient satisfaction with healthcare services. That is why there is a distinct need for the development of a new tool or adaptation of existing instrument of satisfaction measurement, which would be unitized for all medical organizations in the Russian Federation 

  11. A pilot study to evaluate the magnitude of association of the use of electronic personal health records with patient activation and empowerment in HIV-infected veterans

    Directory of Open Access Journals (Sweden)

    Pierre-Cédric B. Crouch

    2015-03-01

    Full Text Available The HITECH Act signed into law in 2009 requires hospitals to provide patients with electronic access to their health information through an electronic personal health record (ePHR in order to receive Medicare/Medicaid incentive payments. Little is known about who uses these systems or the impact these systems will have on patient outcomes in HIV care. The health care empowerment model provides rationale for the hypothesis that knowledge from an electronic personal health record can lead to greater patient empowerment resulting in improved outcomes. The objective was to determine the patient characteristics and patient activation, empowerment, satisfaction, knowledge of their CD4, Viral Loads, and antiretroviral medication, and medication adherence outcomes associated with electronic personal health record use in Veterans living with HIV at the San Francisco VA Medical Center. The participants included HIV-Infected Veterans receiving care in a low volume HIV-clinic at the San Francisco VA Medical Center, divided into two groups of users and non-users of electronic personal health records. The research was conducted using in-person surveys either online or on paper and data abstraction from medical records for current anti-retroviral therapy (ART, CD4 count, and plasma HIV-1 viral load. The measures included the Patient Activation Measure, Health Care Empowerment Inventory, ART adherence, provider satisfaction, current CD4 count, current plasma viral load, knowledge of current ART, knowledge of CD4 counts, and knowledge of viral load. In all, 40 participants were recruited. The use of electronic personal health records was associated with significantly higher levels of patient activation and levels of patient satisfaction for getting timely appointments, care, and information. ePHR was also associated with greater proportions of undetectable plasma HIV-1 viral loads, of knowledge of current CD4 count, and of knowledge of current viral load. The

  12. Capacity Building in Open Medical Record System (OpenMRS) in ...

    International Development Research Centre (IDRC) Digital Library (Canada)

    Capacity Building in Open Medical Record System (OpenMRS) in Rwanda ... Partners in Health (PIH), an international nongovernmental organization, has demonstrated the usefulness of ... Journal articles ... will fund social science, population and public health, and health systems research relevant to the emerging crisis.

  13. Nurses’ attitudes and behaviors on patient medication education

    Directory of Open Access Journals (Sweden)

    Bowen JF

    2017-06-01

    Full Text Available Background: Medication education is vital for positive patient outcomes. However, there is limited information about optimal medication education by nurses during hospitalization and care transitions. Objective: Examine nurses’ attitudes and behaviors regarding the provision of patient medication education. The secondary objectives were to determine if nurses’ medication education attitudes explain their behaviors, describe nurses’ confidence in patient medication knowledge and abilities, and identify challenges to and improvements for medication education. Methods: A cross sectional survey was administered to nurses servicing internal medicine, cardiology, or medical-surgical patients. Results: Twenty-four nurses completed the survey. Greater than 90% of nurses believed it is important to provide information on new medications and medical conditions, utilize resources, assess patient understanding and adherence, and use open ended question. Only 58% believed it is important to provide information on refill medications. Greater than 80% of nurses consistently provided information on new medications, assessed patient understanding, and utilized resources, but one-third or less used open-ended questions or provided information on refill medications. Most nurses spend 5-9 minutes per patient on medication education and their attitudes matched the following medication education behaviors: assessing adherence (0.57; p<0.01, providing information on new medications (0.52; p<0.05, using open-ended questions (0.51; p<0.01, and providing information on refill medications (0.39; p<0.05. Nurses had higher confidence that patients can understand and follow medication instructions, and identify names and purpose of their medications. Nurses had lower confidence that patients know what to expect from their medication or how to manage potential side effects. Communication, including language barriers and difficulty determining the patient

  14. How is adult patient adherence recorded in orthodontists’ clinical notes? A mixed-method case-note study

    Directory of Open Access Journals (Sweden)

    Al Shammary N

    2017-10-01

    Full Text Available Nawaf Al Shammary,1 Koula Asimakopoulou,1 Fraser McDonald,2 Jonathon T Newton,1 Sasha Scambler1 1Division of Population and Patient Health, 2Craniofacial Development and Stem Cell Biology Department, King’s College London Dental Institute, London, UKBackground: Patient adherence in orthodontic treatment is extremely important as it is linked with better treatment outcomes. Despite its importance, however, there is no shared definition of the concept. This makes the recording of adherence-related behaviors in patient notes difficult. The current study explored how, and to what extent adherence is recorded in adult patients’ medical records by orthodontists working in a large National Health Service (NHS London hospital.Materials and methods: A mixed-methods approach was used. A total of 17 clinicians with a mean age of 31 years (SD =4.87 provided N=20 case notes spanning N=324 appointments with patients they judged to be non-adherent. The notes were inspected for evidence of recording of patient adherence using adherence indicators identified in the literature.Results: The term “adherence” did not feature in any notes. The quantitative analysis showed that the three most frequent adherence-related behaviors recorded in notes were “oral hygiene,” “appointment attendance” and “breakages of appliances.” Qualitative analysis not only confirmed these factors but also showed that 1 the clinical aspects of treatment, 2 clinician–patient interaction factors and 3 patient attitudes also featured. This part of the analysis also highlighted inconsistencies across case notes in terms of the amount of information being recorded.Conclusion: Adherence as a term does not feature in the clinical case notes of clinician-identified non-adherent adult patients, while predictors of adherence are recorded with varying degrees of consistency. Keywords: adherence, adults, orthodontic treatment

  15. An Electronic Medical Record Alert Intervention to Improve HPV Vaccination Among Eligible Male College Students at a University Student Health Center.

    Science.gov (United States)

    Martin, Suzanne; Warner, Echo L; Kirchhoff, Anne C; Mooney, Ryan; Martel, Laura; Kepka, Deanna

    2018-02-16

    This pilot study aims to improve HPV vaccination for college aged males at a student health center. The first part of the study consisted of a focus group that assessed the barriers and facilitators of HPV vaccination among healthcare providers and clinic staff (N = 16). Providers reported missed opportunities for HPV vaccination. For the second part of the study, providers and staff reviewed medical records of patients ages 18-26 with student health insurance and with HPV vaccine at baseline (12/1/2014 to 7/31/2015) and follow-up (12/1/2015 to 7/31/2016). A computer-automated EMR alert was generated in the medical record of eligible male patients (N = 386). Z-scores were estimated for two-sample proportions to measure change in HPV vaccine rates at baseline and follow-up for males and females. HPV vaccine initiation rates increased among males (baseline: 5.2% follow-up: 25.1%, p HPV vaccine initiation rates among insured college-aged males.

  16. Computational Diagnostic: A Novel Approach to View Medical Data.

    Energy Technology Data Exchange (ETDEWEB)

    Mane, K. K. (Ketan Kirtiraj); Börner, K. (Katy)

    2007-01-01

    A transition from traditional paper-based medical records to electronic health record is largely underway. The use of electronic records offers tremendous potential to personalize patient diagnosis and treatment. In this paper, we discuss a computational diagnostic tool that uses digital medical records to help doctors gain better insight about a patient's medical condition. The paper details different interactive features of the tool which offer potential to practice evidence-based medicine and advance patient diagnosis practices. The healthcare industry is a constantly evolving domain. Research from this domain is often translated into better understanding of different medical conditions. This new knowledge often contributes towards improved diagnosis and treatment solutions for patients. But the healthcare industry lags behind to seek immediate benefits of the new knowledge as it still adheres to the traditional paper-based approach to keep track of medical records. However recently we notice a drive that promotes a transition towards electronic health record (EHR). An EHR stores patient medical records in digital format and offers potential to replace the paper health records. Earlier attempts of an EHR replicated the paper layout on the screen, representation of medical history of a patient in a graphical time-series format, interactive visualization with 2D/3D generated images from an imaging device. But an EHR can be much more than just an 'electronic view' of the paper record or a collection of images from an imaging device. In this paper, we present an EHR called 'Computational Diagnostic Tool', that provides a novel computational approach to look at patient medical data. The developed EHR system is knowledge driven and acts as clinical decision support tool. The EHR tool provides two visual views of the medical data. Dynamic interaction with data is supported to help doctors practice evidence-based decisions and make judicious

  17. Medication abortion: Potential for improved patient access through pharmacies.

    Science.gov (United States)

    Raifman, Sarah; Orlando, Megan; Rafie, Sally; Grossman, Daniel

    2018-05-08

    To discuss the potential for improving access to early abortion care through pharmacies in the United States. Despite the growing use of medications to induce termination of early pregnancy, pharmacist involvement in abortion care is currently limited. The Food and Drug Administration's Risk Evaluation and Mitigation Strategy (REMS) for Mifeprex® (mifepristone 200 mg), the principal drug used in early medication abortion, prohibits the dispensing of the drug by prescription at pharmacies. This commentary reviews the pharmacology of medication abortion with the use of mifepristone and misoprostol, as well as aspects of service delivery and data on safety, efficacy, and acceptability. Given its safety record, mifepristone no longer fits the profile of a drug that requires an REMS. The recent implementation of pharmacy dispensing of mifepristone in community pharmacies in Australia and some provinces of Canada has improved access to medication abortion by increasing the number of medication abortion providers, particularly in rural areas. Provision of mifepristone in pharmacies, which involves dispensing and patient counseling, would likely improve access to early abortion in the United States without increasing risks to women. Copyright © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

  18. Compliance with referrals to medical specialist care: patient and general practice determinants: a cross-sectional study.

    Science.gov (United States)

    van Dijk, Christel E; de Jong, Judith D; Verheij, Robert A; Jansen, Tessa; Korevaar, Joke C; de Bakker, Dinny H

    2016-02-01

    In a gatekeeper system, primary care physicians and patients jointly decide whether or not medical specialist care is needed. However, it is the patient who decides to actually use the referral. Referral non-compliance could delay diagnosis and treatment. The objective of this study was to assess patient compliance with a referral to medical specialist care and identify patient and practice characteristics that are associated with it. Observational study using data on 48,784 referrals to medical specialist care derived from electronic medical records of 58 general practices for the period 2008-2010. Referral compliance was based on claims data of medical specialist care. Logistic multilevel regression analyses were conducted to determine associations between patient and general practice characteristics and referral compliance. In 86.6% of the referrals, patients complied. Patient and not practice characteristics were significantly associated with compliance. Patients from deprived urban areas and patients aged 18-44 years were less likely to comply, whereas patients aged 65 years and older were more likely to comply. About 1 in 8 patients do not use their referral. These patients may not receive adequate care. Demographic and socio-economic factors appear to affect compliance. The results of this study may be used to make general practitioners more aware that some patients are more likely to be noncompliant with referrals.

  19. Medication absorption for patients with an ileostomy.

    Science.gov (United States)

    Moore, Susan

    The Association of Stoma Care Nurses UK (2013) has stressed that it is the role of the stoma care nurse to provide education to patients, carers, prescribers and other nurses. This includes the area of medication management. Ensuring patients with an ileostomy receive their medication in a form they can absorb is of importance to every stoma care nurse. Prescribing for patients with a stoma calls for special care. Each patient with an ileostomy requires assessment of their medication regimen for the purpose of identifying potential medical absorption issues. However, from an extensive literature search, it is evident that there is very little literature published on this subject. This article looks at the considerations to take into account when prescribing medication for ileostomy patients, and examines the results of a clinical audit on medication prescribers' knowledge of the impact of ileostomy formation on the absorption of medication.

  20. Integration of SNOMED CT into the OpenMRS electronic medical record system framework

    CSIR Research Space (South Africa)

    Gerber, A

    2008-11-01

    Full Text Available Integrating a mechanism to store, retrieve and use clinical data with a system to manage medical records enables better utilisation of medical data and improved healthcare. This poster introduces a research project that aims to extend Open...

  1. Use of and attitudes to a hospital information system by medical secretaries, nurses and physicians deprived of the paper-based medical record: a case report

    Directory of Open Access Journals (Sweden)

    Karlsen Tom H

    2004-10-01

    Full Text Available Abstract Background Most hospitals keep and update their paper-based medical records after introducing an electronic medical record or a hospital information system (HIS. This case report describes a HIS in a hospital where the paper-based medical records are scanned and eliminated. To evaluate the HIS comprehensively, the perspectives of medical secretaries and nurses are described as well as that of physicians. Methods We have used questionnaires and interviews to assess and compare frequency of use of the HIS for essential tasks, task performance and user satisfaction among medical secretaries, nurses and physicians. Results The medical secretaries use the HIS much more than the nurses and the physicians, and they consider that the electronic HIS greatly has simplified their work. The work of nurses and physicians has also become simplified, but they find less satisfaction with the system, particularly with the use of scanned document images. Conclusions Although the basis for reference is limited, the results support the assertion that replacing the paper-based medical record primarily benefits the medical secretaries, and to a lesser degree the nurses and the physicians. The varying results in the different employee groups emphasize the need for a multidisciplinary approach when evaluating a HIS.

  2. The effect of the electronic medical record on nurses' work.

    Science.gov (United States)

    Robles, Jane

    2009-01-01

    The electronic medical record (EMR) is a workplace reality for most nurses. Its advantages include a single consolidated record for each person; capacity for data interfaces and alerts; improved interdisciplinary communication; and evidence-based decision support. EMRs can add to work complexity, by forcing better documentation of previously unrecorded data and/or because of poor design. Well-designed and well-implemented computerized provider order entry (CPOE) systems can streamline nurses' work. Generational differences in acceptance of and facility with EMRs can be addressed through open, healthy communication.

  3. Development of Electronic Medical Record-Based "Rounds Report" Results in Improved Resident Efficiency, More Time for Direct Patient Care and Education, and Less Resident Duty Hour Violations.

    Science.gov (United States)

    Ham, Phillip B; Anderton, Toby; Gallaher, Ryan; Hyrman, Mike; Simmerman, Erika; Ramanathan, Annamalai; Fallaw, David; Holsten, Steven; Howell, Charles Gordon

    2016-09-01

    Surgeons frequently report frustration and loss of efficiency with electronic medical record (EMR) systems. Together, surgery residents and a programmer at Augusta University created a rounds report (RR) summarizing 24 hours of vitals, intake/output, labs, and other values for each inpatient that were previously transcribed by hand. The objective of this study was to evaluate the RR's effect on surgery residents. Surgery residents were queried to assess the RR's impact. Outcome measures were time spent preparing for rounds, direct patient care time, educational activity time, rates of incorrect/incomplete data on rounds, and rate of duty hour violations. Hospital wide, 17,200 RRs were generated in the 1-month study. Twenty-three surgery residents participated. Time spent preparing for rounds decreased per floor patient (15.6 ± 3.0 vs 6.0 ± 1.2, P care unit patient (19.9 ± 2.9 vs 7.5 ± 1.2 P care increased from 45.1 ± 5.6 to 54.0 ± 5.7 per cent (P = 0.0044). Educational activity time increased from 35.2 ± 5.4 to 54.7 ± 7.1 minutes per resident per day (P = 0.0004). Reported duty hour violations decreased 58 per cent (P care at academic medical centers.

  4. Psychiatric side effects of ketamine in hospitalized medical patients administered subanesthetic doses for pain control.

    Science.gov (United States)

    Rasmussen, Keith G

    2014-08-01

    To assess the psychiatric side effects of ketamine when administered in subanesthetic doses to hospitalized patients. It is hypothesized that such effects occur frequently. In this retrospective study, the medical records of 50 patients hospitalized on medical and surgical units at our facility who had continuous intravenous infusions of ketamine for pain or mild sedation were reviewed. Patient progress in the days following the start of ketamine infusion was reviewed and response to ketamine was noted. Twenty-two percent of the patients were noted to have some type of psychiatric reaction to ketamine, including agitation, confusion, and hallucinations. These reactions were relatively short lived, namely, occurring during or shortly after the infusions. No association was found between patient response to ketamine and gender, age, or infusion rate. Awareness of the psychiatric side effects of ketamine is an important consideration for clinicians administering this medication either for pain control or for depressive illness.

  5. 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.

  6. Patient-provider interaction during medication encounters: A study in outpatient pharmacies in the Netherlands.

    Science.gov (United States)

    Koster, Ellen S; van Meeteren, Marijke M; van Dijk, Marloes; van de Bemt, Bart J F; Ensing, Hendrikus T; Bouvy, Marcel L; Blom, Lyda; van Dijk, Liset

    2015-07-01

    To describe communication between pharmacy staff and patients at the counter in outpatient pharmacies. Both content and communication style were investigated. Pharmaceutical encounters in three outpatient pharmacies in the Netherlands were video-recorded. Videos were analyzed based on an observation protocol for the following information: content of encounter, initiator of a theme and pharmacy staff's communication style. In total, 119 encounters were recorded which concerned 42 first prescriptions, 16 first refill prescriptions and 61 follow-up refill prescriptions. During all encounters, discussion was mostly initiated by pharmacy staff (85%). In first prescription encounters topics most frequently discussed included instructions for use (83%) and dosage instructions (95%). In first refill encounters, patient experiences such as adverse effects (44%) and beneficial effects (38%) were regularly discussed in contrast to follow-up refills (7% and 5%). Patients' opinion on medication was hardly discussed. Pharmacy staff in outpatient pharmacies generally provide practical information, less frequently they discuss patients' experiences and seldom discuss patients' perceptions and preferences about prescribed medication. This study shows there is room for improvement, as communication is still not according to professional guidelines. To implement professional guidelines successfully, it is necessary to identify underlying reasons for not following the guidelines. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  7. Patient-centered medical homes for patients with disabilities.

    Science.gov (United States)

    Hernandez, Brigida; Damiani, Marco; Wang, T Arthur; Driscoll, Carolyn; Dellabella, Peter; LePera, Nicole; Mentari, Michael

    2015-01-01

    The patient-centered medical home is an innovative approach to improve health care outcomes. To address the unique needs of patients with intellectual and developmental disabilities (IDDs), a large health care provider reevaluated the National Committee for Quality Assurance's 6 medical home standards: (a) enhance access and continuity, (b) identify and manage patient populations, (c) plan and manage care, (d) provide self-care and community support, (e) track and coordinate care, and (f) measure and improve performance. This article describes issues to consider when serving patients with IDDs.

  8. Therapeutic Value of Medical Marijuana in New Jersey Patients: A Community Partnership Research Endeavor.

    Science.gov (United States)

    Crowell, Tara L

    2017-01-01

    The Public Health Program at Stockton University partnered with the Compassionate Care Foundation to ascertain the impact of medical marijuana on patients in New Jersey. Patients volunteered to complete a survey once a month for 8 months. The survey explored their use, form, and strain of medical marijuana and its influence on pain and 12 other physical and mental health variables. Also, an increase or decrease in other medication taken and any unexpected outcomes were recorded. From a total of 955 patients, patients responding to the surveys varied from 501 for visit 1, 290 for visit 2, to 179 for visit 3. Results provide insight into the diagnoses for which patients used medical marijuana. Results indicate increased mood, general overall condition, and energy as the highest consequences; level of pain in the middle range; and most frequent usage as 3 to 4 times a day. Repeated measures done after visit 2 showed eight statistically significant differences for patients after using medical marijuana: an increase in general quality of life, mobility, and mood, with a decrease in inflammation, intraocular pressure, spasms, seizures, and pain. Results after visit 3 indicated seven significant differences compared to visit 1: decreased seizures, intraocular pressure, spasms, nausea, and pain, along with increased energy and mobility. No differences were found by patient diagnosis or age, but sex-related differences occurred in inflammation, mood, and energy. Results support positive therapeutic benefits of medical marijuana, and despite methodological limitations, our study contributes to the growing body of literature.

  9. When and How Should Clinicians Share Details from a Health Record with Patients with Mental Illness?

    Science.gov (United States)

    Thom, Robyn P; Farrell, Helen M

    2017-03-01

    Stigma associated with mental illness-a public health crisis-is perpetuated by the language used to describe and document it. Psychiatric pathology and how it can be perceived among clinicians contribute to the marginalization of patients, which exacerbates their vulnerability. Clinical documentation of mental illness has long been mired in pejorative language that perpetuates negative assumptions about those with mental illness. Although patients have the legal right to view their health record, sharing mental health notes with patients remains a sensitive issue, largely due to clinicians' fears that review of this content might cause harm, specifically psychiatric destabilization. However, the ethical principles of justice, beneficence, and autonomy as well as nonmaleficence must be considered by clinicians in determining when and how to share psychiatric details from a health record with their patients. © 2017 American Medical Association. All Rights Reserved.

  10. Comparisons between written and computerised patient histories

    NARCIS (Netherlands)

    Quaak, Martien; Westerman, R. Frans; van Bemmel, Jan H.

    1987-01-01

    Patient histories were obtained from 99 patients in three different ways: by a computerised patient interview (patient record), by the usual written interview (medical record), and by the transcribed record, which was a computerised version of the medical record. Patient complaints, diagnostic

  11. Sharing electronic health records: the patient view

    Directory of Open Access Journals (Sweden)

    John Powell

    2006-03-01

    Full Text Available The introduction of a national electronic health record system to the National Health Service (NHS has raised concerns about issues of data accuracy, security and confidentiality. The primary aim of this project was to identify the extent to which primary care patients will allow their local electronic record data to be shared on a national database. The secondary aim was to identify the extent of inaccuracies in the existing primary care records, which will be used to populate the new national Spine. Fifty consecutive attenders to one general practitioner were given a paper printout of their full primary care electronic health record. Participants were asked to highlight information which they would not want to be shared on the national electronic database of records, and information which they considered to be incorrect. There was a 62% response rate (31/50. Five of the 31 patients (16% identified information that they would not want to be shared on the national record system. The items they identified related almost entirely to matters of pregnancy, contraception, sexual health and mental health. Ten respondents (32% identified incorrect information in their records (some of these turned out to be correct on further investigation. The findings in relation to data sharing fit with the commonly held assumption that matters related to sensitive or embarrassing issues, which may affect how the patient will be treated by other individuals or institutions, are most likely to be censored by patients. Previous work on this has tended to ask hypothetical questions concerning data sharing rather than examine a real situation. A larger study of representative samples of patients in both primary and secondary care settings is needed to further investigate issues of data sharing and consent.

  12. Psychodynamics in medically ill patients.

    Science.gov (United States)

    Nash, Sara Siris; Kent, Laura K; Muskin, Philip R

    2009-01-01

    This article explores the role of psychodynamics as it applies to the understanding and treatment of medically ill patients in the consultation-liaison psychiatry setting. It provides historical background that spans the eras from Antiquity (Hippocrates and Galen) to nineteenth-century studies of hysteria (Charcot, Janet, and Freud) and into the twentieth century (Flanders Dunbar, Alexander, Engle, and the DSM). The article then discusses the effects of personality on medical illness, treatment, and patients' ability to cope by reviewing the works of Bibring, Kahana, and others. The important contribution of attachment theory is reviewed as it pertains the patient-physician relationship and the health behavior of physically ill patients. A discussion of conversion disorder is offered as an example of psychodynamics in action. This article highlights the important impact of countertransference, especially in terms of how it relates to patients who are extremely difficult and "hateful," and explores the dynamics surrounding the topic of physician-assisted suicide, as it pertains to the understanding of a patient's request to die. Some attention is also given to the challenges surrounding the unique experience of residents learning how to treat medically ill patients on the consultation-liaison service. Ultimately, this article concludes that the use and understanding of psychodynamics and psychodynamic theory allows consultation-liaison psychiatrists the opportunity to interpret the life narratives of medically ill patients in a meaningful way that contributes importantly to treatment.

  13. Safeguarding Confidentiality in Electronic Health Records.

    Science.gov (United States)

    Shenoy, Akhil; Appel, Jacob M

    2017-04-01

    Electronic health records (EHRs) offer significant advantages over paper charts, such as ease of portability, facilitated communication, and a decreased risk of medical errors; however, important ethical concerns related to patient confidentiality remain. Although legal protections have been implemented, in practice, EHRs may be still prone to breaches that threaten patient privacy. Potential safeguards are essential, and have been implemented especially in sensitive areas such as mental illness, substance abuse, and sexual health. Features of one institutional model are described that may illustrate the efforts to both ensure adequate transparency and ensure patient confidentiality. Trust and the therapeutic alliance are critical to the provider-patient relationship and quality healthcare services. All of the benefits of an EHR are only possible if patients retain confidence in the security and accuracy of their medical records.

  14. Medical students' agenda-setting abilities during medical interviews.

    Science.gov (United States)

    Roh, HyeRin; Park, Kyung Hye; Jeon, Young-Jee; Park, Seung Guk; Lee, Jungsun

    2015-06-01

    Identifying patients' agendas is important; however, the extent of Korean medical students' agenda-setting abilities is unknown. The study aim was to investigate the patterns of Korean medical students' agenda solicitation. A total of 94 third-year medical students participated. One scenario involving a female patient with abdominal pain was created. Students were video-recorded as they interviewed the patient. To analyze whether students identify patients' reasons for visiting, a checklist was developed based on a modified version of the Calgary-Cambridge Guide to the Medical Interview: Communication Process checklist. The duration of the patient's initial statement of concerns was measured in seconds. The total number of patient concerns expressed before interruption and the types of interruption effected by the medical students were determined. The medical students did not explore the patients' concerns and did not negotiate an agenda. Interruption of the patient's opening statement occurred in 4.62±2.20 seconds. The most common type of initial interruption was a recompleter (79.8%). Closed-ended questions were the most common question type in the second and third interruptions. Agenda setting should be emphasized in the communication skills curriculum of medical students. The Korean Clinical Skills Exam must assess medical students' ability to set an agenda.

  15. Patients' online access to their electronic health records and linked online services: a systematic review in primary care.

    Science.gov (United States)

    Mold, Freda; de Lusignan, Simon; Sheikh, Aziz; Majeed, Azeem; Wyatt, Jeremy C; Quinn, Tom; Cavill, Mary; Franco, Christina; Chauhan, Umesh; Blakey, Hannah; Kataria, Neha; Arvanitis, Theodoros N; Ellis, Beverley

    2015-03-01

    Online access to medical records by patients can potentially enhance provision of patient-centred care and improve satisfaction. However, online access and services may also prove to be an additional burden for the healthcare provider. To assess the impact of providing patients with access to their general practice electronic health records (EHR) and other EHR-linked online services on the provision, quality, and safety of health care. A systematic review was conducted that focused on all studies about online record access and transactional services in primary care. Data sources included MEDLINE, Embase, CINAHL, Cochrane Library, EPOC, DARE, King's Fund, Nuffield Health, PsycINFO, OpenGrey (1999-2012). The literature was independently screened against detailed inclusion and exclusion criteria; independent dual data extraction was conducted, the risk of bias (RoB) assessed, and a narrative synthesis of the evidence conducted. A total of 176 studies were identified, 17 of which were randomised controlled trials, cohort, or cluster studies. Patients reported improved satisfaction with online access and services compared with standard provision, improved self-care, and better communication and engagement with clinicians. Safety improvements were patient-led through identifying medication errors and facilitating more use of preventive services. Provision of online record access and services resulted in a moderate increase of e-mail, no change on telephone contact, but there were variable effects on face-to-face contact. However, other tasks were necessary to sustain these services, which impacted on clinician time. There were no reports of harm or breaches in privacy. While the RoB scores suggest many of the studies were of low quality, patients using online services reported increased convenience and satisfaction. These services positively impacted on patient safety, although there were variations of record access and use by specific ethnic and socioeconomic groups

  16. The place of SGML and HTML in building electronic patient records.

    Science.gov (United States)

    Pitty, D; Gordon, C; Reeves, P; Capey, A; Vieyra, P; Rickards, T

    1997-01-01

    The authors are concerned that, although popular, SGML (Standard Generalized Markup Language) is only one approach to capturing, storing, viewing and exchanging healthcare information and does not provide a suitable paradigm for solving most of the problems associated with paper based patient record systems. Although a discussion of the relative merits of SGML, HTML (HyperText Markup Language) may be interesting, we feel such a discussion is avoiding the real issues associated with the most appropriate way to model, represent, and store electronic patient information in order to solve healthcare problems, and therefore the medical informatics community should firstly concern itself with these issues. The paper substantiates this viewpoint and concludes with some suggestions of how progress can be made.

  17. Evaluation of natural language processing from emergency department computerized medical records for intra-hospital syndromic surveillance

    Directory of Open Access Journals (Sweden)

    Pagliaroli Véronique

    2011-07-01

    Full Text Available Abstract Background The identification of patients who pose an epidemic hazard when they are admitted to a health facility plays a role in preventing the risk of hospital acquired infection. An automated clinical decision support system to detect suspected cases, based on the principle of syndromic surveillance, is being developed at the University of Lyon's Hôpital de la Croix-Rousse. This tool will analyse structured data and narrative reports from computerized emergency department (ED medical records. The first step consists of developing an application (UrgIndex which automatically extracts and encodes information found in narrative reports. The purpose of the present article is to describe and evaluate this natural language processing system. Methods Narrative reports have to be pre-processed before utilizing the French-language medical multi-terminology indexer (ECMT for standardized encoding. UrgIndex identifies and excludes syntagmas containing a negation and replaces non-standard terms (abbreviations, acronyms, spelling errors.... Then, the phrases are sent to the ECMT through an Internet connection. The indexer's reply, based on Extensible Markup Language, returns codes and literals corresponding to the concepts found in phrases. UrgIndex filters codes corresponding to suspected infections. Recall is defined as the number of relevant processed medical concepts divided by the number of concepts evaluated (coded manually by the medical epidemiologist. Precision is defined as the number of relevant processed concepts divided by the number of concepts proposed by UrgIndex. Recall and precision were assessed for respiratory and cutaneous syndromes. Results Evaluation of 1,674 processed medical concepts contained in 100 ED medical records (50 for respiratory syndromes and 50 for cutaneous syndromes showed an overall recall of 85.8% (95% CI: 84.1-87.3. Recall varied from 84.5% for respiratory syndromes to 87.0% for cutaneous syndromes. The

  18. A novel decentralized hierarchical access control scheme for the medical scenario

    DEFF Research Database (Denmark)

    Eskeland, Sigurd; Prasad, Neeli R.

    2006-01-01

    to be the property of the corresponding patient, it is justified that patients should have the opportunity to exert control over their own data. In this paper, we propose a cryptographic access control scheme allowing patients to grant medical teams authorizations to access their medical data. Moreover......Electronic patient records contains highly personal and confidential information that it is essential to keep private. Thus, only the medical professionals providing care to a patient should access the patient record of the concerning patient. As personal medical data can be considered......, the hierarchical aspects of teams are taken into account so that the modules of the patient record are to be accessed according to the individual privileges of the medical professionals of the team. Thus, more privileged users obtain larger portions of the data than less privileged users....

  19. A novel decentralized hierarchical access control scheme for the medical scenario

    DEFF Research Database (Denmark)

    Eskeland, Sigurd; Prasad, Neeli R.

    2006-01-01

    Electronic patient records contains highly personal and confidential information that it is essential to keep private. Thus, only the medical professionals providing care to a patient should access the patient record of the concerning patient. As personal medical data can be considered...... to be the property of the corresponding patient, it is justified that patients should have the opportunity to exert control over their own data. In this paper, we propose a cryptographic access control scheme allowing patients to grant medical teams authorizations to access their medical data. Moreover......, the hierarchical aspects of teams are taken into account so that the modules of the patient record are to be accessed according to the individual privileges of the medical professionals of the team. Thus, more privileged users obtain larger portions of the data than less privileged users....

  20. 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.

  1. Lessons Learned from Implementing the Patient-Centered Medical Home

    Directory of Open Access Journals (Sweden)

    Ellen P. Green

    2012-01-01

    Full Text Available The Patient-Centered Medical Home (PCMH is a primary care model that provides coordinated and comprehensive care to patients to improve health outcomes. This paper addresses practical issues that arise when transitioning a traditional primary care practice into a PCMH recognized by the National Committee for Quality Assurance (NCQA. Individual organizations' experiences with this transition were gathered at a PCMH workshop in Alexandria, Virginia in June 2010. An analysis of their experiences has been used along with a literature review to reveal common challenges that must be addressed in ways that are responsive to the practice and patients’ needs. These are: NCQA guidance, promoting provider buy-in, leveraging electronic medical records, changing office culture, and realigning workspace in the practice to accommodate services needed to carry out the intent of PCMH. The NCQA provides a set of standards for implementing the PCMH model, but these standards lack many specifics that will be relied on in location situations. While many researchers and providers have made critiques, we see this vagueness as allowing for greater flexibility in how a practice implements PCMH.

  2. Incorporation of medical informatics and information technology as core components of undergraduate medical education - time for change!

    Science.gov (United States)

    Otto, Anthony; Kushniruk, Andre

    2009-01-01

    It is generally accepted that Information Technology (IT) is a highly desirable and a very necessary ingredient of modern health care. Review of available literature reveals a paucity of medical informatics and information technology courses in undergraduate medical curricula and a lack of research to assess the effectiveness of medical informatics in undergraduate medical education. The need for such initiatives is discussed and a pilot project is described that evaluated the effectiveness of education in the use of Electronic Medical Record (EMR) applications. Educational activities, for example, could be medical students conducting virtual medical encounters or interacting with EMR applications. An EMR application, which was used in several related projects, has been adapted to the educational environment: standardized patient records can be created and cloned so that individual students can interact with a "standard" patient and alter the patient's data.

  3. The Impact of Health Literacy on a Patient's Decision to Adopt a Personal Health Record

    Science.gov (United States)

    Noblin, Alice M.; Wan, Thomas T. H.; Fottler, Myron

    2012-01-01

    Health literacy is a concept that describes a patient's ability to understand materials provided by physicians or other providers. Several factors, including education level, income, and age, can influence health literacy. Research conducted at one medical practice in Florida indicated that in spite of the patients’ relatively low education level, the majority indicated a broad acceptance of personal health record (PHR) technology. The key variable explaining patient willingness to adopt a PHR was the patient's health literacy as measured by the eHealth Literacy Scale (eHEALS). Adoption and use rates may also depend on the availability of office staff for hands-on training as well as assistance with interpretation of medical information. It is hoped that technology barriers will disappear over time, and usefulness of the information will promote increased utilization of PHRs. Patient understanding of the information remains a challenge that must be overcome to realize the full potential of PHRs. PMID:23209454

  4. Exploring Factors Affecting Emergency Medical Services Staffs' Decision about Transporting Medical Patients to Medical Facilities

    OpenAIRE

    Ebrahimian, Abbasali; Seyedin, Hesam; Jamshidi-Orak, Roohangiz; Masoumi, Gholamreza

    2014-01-01

    Transfer of patients in medical emergency situations is one of the most important missions of emergency medical service (EMS) staffs. So this study was performed to explore affecting factors in EMS staffs’ decision during transporting of patients in medical situations to medical facilities. The participants in this qualitative study consisted of 18 EMS staffs working in prehospital care facilities in Tehran, Iran. Data were gathered through semistructured interviews. The data were analyzed u...

  5. Utilization of Evidence-Based Secondary Prevention Medications at the Time of Discharge in Patients with Acute Coronary Syndrome (ACS) in Qatar.

    Science.gov (United States)

    El-Hajj, Maguy S; Saad, Ahned; Al-Suwaidi, Jassim; Al-Marridi, Wafa Z; Elkhalifa, Dana H; Mohamed, Alaa A; Mahfoud, Ziyad R

    2016-01-01

    In Qatar, ACS (Acute Coronary Syndrome) has become the leading cause of morbidity and mortality. Guidelines recommend that ACS patients should receive indefinite treatment with antiplatelets, β-blockers, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) and statins. The study objectives were to assess the use of evidence-based secondary prevention medication at discharge among ACS patients in Qatar and to determine the clinical and demographic characteristics associated with the use of these medications. A retrospective medical record review was conducted at the Heart Hospital in Qatar. A random sample of 1068 ACS patients was selected. Patient characteristics were summarized. Prevalence of medications at discharge were computed for each medication as well as for medication combinations. Multiple logistic regression was used to detect patient variables that were associated with the outcomes. A p≤0.05 was considered significant. -Percentage of ACS patients discharged on each of the following medications: antiplatelets (aspirin, clopidogrel), β-blockers, ACEI or ARBs and statins and on the combination of these medications-Association between the use of these medications and patient characteristics. In total, 1064 records were reviewed. The majority were males (85.3%) and about 1 in 5 (18.7%) were Qatari. At discharge, patients were prescribed the following: aspirin (96.0%), clopidogrel (92.0%), β-blockers (90.6%) and statins (97.7%). ACEI and ARBs were prescribed to 63.5 and 11.3%, respectively. The concurrent 4 medications (aspirin or clopidogrel, statins or other lowering cholesterol medication, β-blockers and ACEI or ARB) were prescribed to 773 patients (77.8%; 95% confidence interval: 75.2-80.4%). Being overweight or obese, and having PCI (percutaneous coronary intervention) or hypertension were associated with higher prescription of the concurrent medications. Those with diabetes had a 52% increase in the odds of

  6. Agreement between questionnaire and medical records on some health and socioeconomic problems among poisoning cases

    Directory of Open Access Journals (Sweden)

    Fathelrahman Ahmed I

    2009-09-01

    Full Text Available Abstract Background The main objective of the present study was to evaluate the agreement between questionnaire and medical records on some health and socioeconomic problems among poisoning cases. Methods Cross-sectional sample of 100 poisoning cases consecutively admitted to the Hospital Pulau Pinang, Malaysia during the period from September 2003 to February 2004 were studied. Data on health and socioeconomic problems were collected both by self-administered questionnaire and from medical records. Agreement between the two sets of data was assessed by calculating the concordance rate, Kappa (k and PABAK. McNemar statistic was used to test differences between categories. Results Data collected by questionnaire and medical records showed excellent agreement on the "marital status"; good agreements on "chronic illness", "psychiatric illness", and "previous history of poisoning"; and fair agreements on "at least one health problem", and "boy-girl friends problem". PABAK values suggest better agreements' measures. Conclusion There were excellent to good agreements between questionnaire and medical records on the marital status and most of the health problems and fair to poor agreements on the majority of socioeconomic problems. The implications of those findings were discussed.

  7. Does applying technology throughout the medication use process improve patient safety with antineoplastics?

    Science.gov (United States)

    Bubalo, Joseph; Warden, Bruce A; Wiegel, Joshua J; Nishida, Tess; Handel, Evelyn; Svoboda, Leanne M; Nguyen, Lam; Edillo, P Neil

    2014-12-01

    Medical errors, in particular medication errors, continue to be a troublesome factor in the delivery of safe and effective patient care. Antineoplastic agents represent a group of medications highly susceptible to medication errors due to their complex regimens and narrow therapeutic indices. As the majority of these medication errors are frequently associated with breakdowns in poorly defined systems, developing technologies and evolving workflows seem to be a logical approach to provide added safeguards against medication errors. This article will review both the pros and cons of today's technologies and their ability to simplify the medication use process, reduce medication errors, improve documentation, improve healthcare costs and increase provider efficiency as relates to the use of antineoplastic therapy throughout the medication use process. Several technologies, mainly computerized provider order entry (CPOE), barcode medication administration (BCMA), smart pumps, electronic medication administration record (eMAR), and telepharmacy, have been well described and proven to reduce medication errors, improve adherence to quality metrics, and/or improve healthcare costs in a broad scope of patients. The utilization of these technologies during antineoplastic therapy is weak at best and lacking for most. Specific to the antineoplastic medication use system, the only technology with data to adequately support a claim of reduced medication errors is CPOE. In addition to the benefits these technologies can provide, it is also important to recognize their potential to induce new types of errors and inefficiencies which can negatively impact patient care. The utilization of technology reduces but does not eliminate the potential for error. The evidence base to support technology in preventing medication errors is limited in general but even more deficient in the realm of antineoplastic therapy. Though CPOE has the best evidence to support its use in the

  8. Training and development needs of medical record staff at the Korle ...

    African Journals Online (AJOL)

    Ghana Library Journal ... Though the medical record services play an important role in health care delivery, indications are that the ... This neglect has far reaching implications for the quality of service required from the Ghana Health Service.

  9. Patient Perceptions of Electronic Health Records

    Science.gov (United States)

    Lulejian, Armine

    2011-01-01

    Research objective. Electronic Health Records (EHR) are expected to transform the way medicine is delivered with patients/consumers being the intended beneficiaries. However, little is known regarding patient knowledge and attitudes about EHRs. This study examined patient perceptions about EHR. Study design. Surveys were administered following…

  10. Validation of fragility fractures in primary care electronic medical records: A population-based study.

    Science.gov (United States)

    Martinez-Laguna, Daniel; Soria-Castro, Alberto; Carbonell-Abella, Cristina; Orozco-López, Pilar; Estrada-Laza, Pilar; Nogues, Xavier; Díez-Perez, Adolfo; Prieto-Alhambra, Daniel

    2017-11-28

    Electronic medical records databases use pre-specified lists of diagnostic codes to identify fractures. These codes, however, are not specific enough to disentangle traumatic from fragility-related fractures. We report on the proportion of fragility fractures identified in a random sample of coded fractures in SIDIAP. Patients≥50 years old with any fracture recorded in 2012 (as per pre-specified ICD-10 codes) and alive at the time of recruitment were eligible for this retrospective observational study in 6 primary care centres contributing to the SIDIAP database (www.sidiap.org). Those with previous fracture/s, non-responders, and those with dementia or a serious psychiatric disease were excluded. Data on fracture type (traumatic vs fragility), skeletal site, and basic patient characteristics were collected. Of 491/616 (79.7%) patients with a registered fracture in 2012 who were contacted, 331 (349 fractures) were included. The most common fractures were forearm (82), ribs (38), and humerus (32), and 225/349 (64.5%) were fragility fractures, with higher proportions for classic osteoporotic sites: hip, 91.7%; spine, 87.7%; and major fractures, 80.5%. This proportion was higher in women, the elderly, and patients with a previously coded diagnosis of osteoporosis. More than 4 in 5 major fractures recorded in SIDIAP are due to fragility (non-traumatic), with higher proportions for hip (92%) and vertebral (88%) fracture, and a lower proportion for fractures other than major ones. Our data support the validity of SIDIAP for the study of the epidemiology of osteoporotic fractures. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

  11. Supporting information retrieval from electronic health records: A report of University of Michigan's nine-year experience in developing and using the Electronic Medical Record Search Engine (EMERSE).

    Science.gov (United States)

    Hanauer, David A; Mei, Qiaozhu; Law, James; Khanna, Ritu; Zheng, Kai

    2015-06-01

    This paper describes the University of Michigan's nine-year experience in developing and using a full-text search engine designed to facilitate information retrieval (IR) from narrative documents stored in electronic health records (EHRs). The system, called the Electronic Medical Record Search Engine (EMERSE), functions similar to Google but is equipped with special functionalities for handling challenges unique to retrieving information from medical text. Key features that distinguish EMERSE from general-purpose search engines are discussed, with an emphasis on functions crucial to (1) improving medical IR performance and (2) assuring search quality and results consistency regardless of users' medical background, stage of training, or level of technical expertise. Since its initial deployment, EMERSE has been enthusiastically embraced by clinicians, administrators, and clinical and translational researchers. To date, the system has been used in supporting more than 750 research projects yielding 80 peer-reviewed publications. In several evaluation studies, EMERSE demonstrated very high levels of sensitivity and specificity in addition to greatly improved chart review efficiency. Increased availability of electronic data in healthcare does not automatically warrant increased availability of information. The success of EMERSE at our institution illustrates that free-text EHR search engines can be a valuable tool to help practitioners and researchers retrieve information from EHRs more effectively and efficiently, enabling critical tasks such as patient case synthesis and research data abstraction. EMERSE, available free of charge for academic use, represents a state-of-the-art medical IR tool with proven effectiveness and user acceptance. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

  12. Formalized Medical Guidelines and a Structured Electronic Health Record.

    Czech Academy of Sciences Publication Activity Database

    Peleška, Jan; Anger, Z.; Buchtela, David; Šebesta, K.; Tomečková, Marie; Veselý, Arnošt; Zvára, K.; Zvárová, Jana

    2005-01-01

    Roč. 11, - (2005), s. 4652-4656 ISSN 1727-1983. [EMBEC'05. European Medical and Biomedical Conference /3./. Prague, 20.11.2005-25.11.2005] R&D Projects: GA AV ČR 1ET200300413 Institutional research plan: CEZ:AV0Z10300504 Keywords : formalization of guidelines in cardilogy * GLIF model * structure electronic health record * algorithm in cardiovascular diagnostics and treatment Subject RIV: BD - Theory of Information

  13. Job characteristic perception and intrinsic motivation in medical record department staff.

    Science.gov (United States)

    Isfahani, Sakineh Saghaeiannejad; Bahrami, Soosan; Torki, Sedighe

    2013-01-01

    Human resources are key factors in service organizations like hospitals. Therefore, motivating human recourses to achieve the objectives of an organization is important. Job enrichment is a strategy used to increase job motivation in staffs. The goal of the current study is to determine the relationship between job characteristics and intrinsic motivation in medical record staff in hospitals related to Medical Science University in Isfahan in 2011-2012 academic year. The type of the study is descriptive and corelational of multi variables. The population of the study includes all the medical record staffs of medical record department working in Medical Science hospitals of Isfahan. One hundred twentyseven subjects were selected by conducting a census. In the present study, data collected by using two questionnaires of job characteristics devised by Hackman and Oldeham, and of intrinsic motivation. Content validity was confirmed by experts and its reliability was calculated through coefficient of Cronbach's alpha (r1 = 0.84- r2 = 0.94). The questionnaires completed were entered into SPSS(18) software; furthermore, statistical analysis done descriptively (frequency percent, mean, standard deviation, Pierson correlation coefficient,...) and inferentially (multiple regression, MANOVA, LSD). A significant relationship between job characteristics as well as its elements (skill variety, task identity, task significance, autonomy and feedback) and intrinsic motivation was noticed. (p intrinsic motivation was significant and job feedback had the most impact upon the intrinsic motivation. No significant difference was noticed among the mean amounts of job characteristic perception according to age, gender, level of education, and the kind of educational degree in hospitals. However, there was a significant difference among the mean amounts of job characteristic perception according to the unit of service and the years of servicein hospitals. The findings show that all job

  14. 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.

  15. 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.

  16. 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

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

  17. Recognition and pseudonymisation of medical records for secondary use.

    Science.gov (United States)

    Heurix, Johannes; Fenz, Stefan; Rella, Antonio; Neubauer, Thomas

    2016-03-01

    Health records rank among the most sensitive personal information existing today. An unwanted disclosure to unauthorised parties usually results in significant negative consequences for an individual. Therefore, health records must be adequately protected in order to ensure the individual's privacy. However, health records are also valuable resources for clinical studies and research activities. In order to make the records available for privacy-preserving secondary use, thorough de-personalisation is a crucial prerequisite to prevent re-identification. This paper introduces MEDSEC, a system which automatically converts paper-based health records into de-personalised and pseudonymised documents which can be accessed by secondary users without compromising the patients' privacy. The system converts the paper-based records into a standardised structure that facilitates automated processing and the search for useful information.

  18. Ranking Medical Terms to Support Expansion of Lay Language Resources for Patient Comprehension of Electronic Health Record Notes: Adapted Distant Supervision Approach.

    Science.gov (United States)

    Chen, Jinying; Jagannatha, Abhyuday N; Fodeh, Samah J; Yu, Hong

    2017-10-31

    Medical terms are a major obstacle for patients to comprehend their electronic health record (EHR) notes. Clinical natural language processing (NLP) systems that link EHR terms to lay terms or definitions allow patients to easily access helpful information when reading through their EHR notes, and have shown to improve patient EHR comprehension. However, high-quality lay language resources for EHR terms are very limited in the public domain. Because expanding and curating such a resource is a costly process, it is beneficial and even necessary to identify terms important for patient EHR comprehension first. We aimed to develop an NLP system, called adapted distant supervision (ADS), to rank candidate terms mined from EHR corpora. We will give EHR terms ranked as high by ADS a higher priority for lay language annotation-that is, creating lay definitions for these terms. Adapted distant supervision uses distant supervision from consumer health vocabulary and transfer learning to adapt itself to solve the problem of ranking EHR terms in the target domain. We investigated 2 state-of-the-art transfer learning algorithms (ie, feature space augmentation and supervised distant supervision) and designed 5 types of learning features, including distributed word representations learned from large EHR data for ADS. For evaluating ADS, we asked domain experts to annotate 6038 candidate terms as important or nonimportant for EHR comprehension. We then randomly divided these data into the target-domain training data (1000 examples) and the evaluation data (5038 examples). We compared ADS with 2 strong baselines, including standard supervised learning, on the evaluation data. The ADS system using feature space augmentation achieved the best average precision, 0.850, on the evaluation set when using 1000 target-domain training examples. The ADS system using supervised distant supervision achieved the best average precision, 0.819, on the evaluation set when using only 100 target

  19. Cancer Screening Among Patients Who Self-Identify as Muslim: Combining Self-Reported Data with Medical Records in a Family Practice Setting.

    Science.gov (United States)

    Lofters, A K; Slater, M; Vahabi, M

    2018-02-01

    Cancer screening is a core component of family medicine but screening inequalities are well documented in Canada for foreign-born persons. Although people of Muslim faith and culture are the fastest growing immigrant population in Canada, there is little information in the literature about their cancer screening practices. Determining screening gaps could inform practice-based quality improvement initiatives. We conducted a retrospective chart review combining patient-level medical record data with self-reported religious affiliation to examine the relationship between religion and cancer screening in a large multi-site urban family practice. Religious affiliation was classified as Muslim, other affiliation, or atheist/no religious affiliation. 5311 patients were included in the study sample. Muslim patients were significantly less likely to prefer English for spoken communication than the other two groups, less likely to be Canadian-born, more likely to have a female family physician, and were over-represented in the lowest income quintile. Muslim women were most likely to be up-to-date on breast cancer screening (85.2 vs. 77.5 % for those with other religions vs. 69.5 % for those with no religious affiliation). There were no significant differences in cancer screening by physician sex. In this pilot study conducted within a primary care practice, we used self-reported data on religious affiliation to examine possible inequities in cancer screening and observed intriguing variations in screening by self-identified religious affiliation. Future efforts to collect and use similar patient-level data should incorporate non-official languages and intensively outreach to patients with less health system contact. Regardless, the family medicine context may be the ideal setting to collect and act on patient-level sociodemographic data such as religious affiliation.

  20. Charging for hospital pharmaceutical services: flat free based on the medication record.

    Science.gov (United States)

    Wyatt, B K

    1979-03-01

    A 200-bed hospital's change in pricing drug products from a cost-plus-fee system to a flat fee per dose based on the medication administration record (MAR) is described. With the flat-fee system, drug charges are not recorded when the drug is dispensed by the pharmacy; data for charging doses are obtained directly from the MAR forms generated by the nursing staff. Charges are 55 cents per oral or suppository dose and $3.00 per injection dose. Drugs administered intravenously, topical drugs, injections costing more than $10.00 per dose, and miscellaneous nondrug items are still charged on a cost-plus-fee basis. Man-hours are saved in the pharmacy department because of the elimination of the pricing function and maintenance of price lists. The need for nursing staff to charge for any doses administered from emergency or Schedule II floor-stock supplies is eliminated. The workload for business office personnel is reduced because the number of individual charges is less than with the cost-plus charging system. The system is accepted by patients and third-party payers and has made a complete unit dose drug distribution system possible at lower cost.