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PubMedDate not supplied

The computer-based patient record and Robert Fulghum's 16 principles.

Robert Fulghum proposed 16 principles learned in kindergarten that he claimed should govern all human activities. How do these principles apply to current efforts to create a computer-based patient record? Fulghum's principles, when recast for the computer-based patient record, emphasize cooperation, privacy, security, and standardization--elements that are easily recognized as essential features of an electronic medical record. However, a number of less frequently discussed issues, such as data quality, integrity, abuse, and misuse can also be considered in terms of Fulghum's principles.

Attitude to Computers↗
PubMed1994

Extraction of SNOMED concepts from medical record texts.

Clinicians have traditionally documented patient data using natural language text. With the increasing prevalence of computer systems in health care, an increasing amount of medical record text will be stored electronically. However, for such textual documents to be indexed, shared, and processed adequately by computers, it will be important to be able to identify concepts in the documents using a common medical terminology. Automated methods for extracting concepts in a standard terminology would enhance retrieval and analysis of medical record data. This paper discusses a method for extracting concepts from medical record documents using the medical terminology SNOMED-III (Systematized Nomenclature of Human and Veterinary Medicine, Version III). The technique employs a linear least squares fit that maps training set phrases to SNOMED concepts. This mapping can be used for unknown text inputs in the same domain as the training set to predict SNOMED concepts that are contained in the document. We have implemented the method in the domain of congestive heart failure for history and physical exam texts. Our system has a reasonable response time. We tested the system over a range of thresholds. The system performed with 90% sensitivity and 83% specificity at the lowest threshold, and 42% sensitivity and 99.9% specificity at the highest threshold.

Algorithms↗
PubMed1994

Automation at the point of care.

Clinical Information Systems (CISs) are systems of microcomputers used at patient bedsides to collect, process, retrieve and display information related to patient care. At our facility, 65 terminals are used in selected units and the CIS has virtually replaced paper charts in daily practice and documentation. Though currently employed in only a small number of hospitals, the use of CISs is expected to grow rapidly during the coming decade.

Computer Systems↗
PubMed1993

Evaluating the accuracy of transcribed clinical data.

This study evaluated the accuracy of data transcribed into a computer-stored record from a handwritten listing of pediatric immunizations. The immunization records of 459 children seen in the UCLA Children's Health Center in March, 1993 were transcribed into a clinical computer system on an ongoing basis. Of these records, 27 (5.9%) were subsequently found to be inaccurate. Reasons for inaccuracy in the transcribed records included incomplete written records, incomplete transcription of written records, and unavailability of immunization records from multiple health-care providers. The utility of a computer-stored clinical record may be adversely affected by unavoidable inaccuracies in transcribed clinical data.

Child↗
PubMed1993

A computer-based tool for generation of progress notes.

IVORY, a computer-based tool that uses clinical findings as the basic unit for composing progress notes, generates progress notes more efficiently than does a character-based word processor. IVORY's clinical findings are contained within a structured vocabulary that we developed to support generation of both prose progress notes and SNOMED III codes. Observational studies of physician participation in the development of IVORY's structured vocabulary have helped us to identify areas where changes are required before IVORY will be acceptable for routine clinical use.

Humans↗
PubMed1993

ARTEMIS: a collaborative framework for health care.

Patient centered healthcare delivery is an inherently collaborative process. This involves a wide range of individuals and organizations with diverse perspectives: primary care physicians, hospital administrators, labs, clinics, and insurance. The key to cost reduction and quality improvement in health care is effective management of this collaborative process. The use of multi-media collaboration technology can facilitate timely delivery of patient care and reduce cost at the same time. During the last five years, the Concurrent Engineering Research Center (CERC), under the sponsorship of DARPA (Defense Advanced Research Projects Agency, recently renamed ARPA) developed a number of generic key subsystems of a comprehensive collaboration environment. These subsystems are intended to overcome the barriers that inhibit the collaborative process. Three subsystems developed under this program include: MONET (Meeting On the Net)--to provide consultation over a computer network, ISS (Information Sharing Server)--to provide access to multi-media information, and PCB (Project Coordination Board)--to better coordinate focussed activities. These systems have been integrated into an open environment to enable collaborative processes. This environment is being used to create a wide-area (geographically distributed) research testbed under DARPA sponsorship, ARTEMIS (Advance Research Testbed for Medical Informatics) to explore the collaborative health care processes. We believe this technology will play a key role in the current national thrust to reengineer the present health-care delivery system.

Computer Communication Networks↗
PubMed1994

Necessity to improve common understanding about the security issues among hospitals in Japan and some feasible approaches.

To improve common understanding about security issues, the importance of classifying the information is stressed, after describing briefly the social background concerning privacy-related problems in Japan. We discuss here the classification only from the following two points of view: (a) the ownership; and (b) how to use. We will derive a two-dimensional fuzzy membership function to describe the ownership and a 'how to use' three-dimensional one as models for describing the framework concerning access right and informed consent.

Computer Security↗