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PubMed1993

[Obstetric data processing with a personal computer].

Update computer technology is an increasingly useful tool in medicine for more accurate documentation, avoidance of multiple documentation, improvement of service performance, quicker and easier data processing and evaluation and hence quality assurance. We developed an obstetric data recording programme for an IBM compatible personal computer according to the MS-DOS command programme. A laser printer with dual paper feed is available. The relational database system Clipper is used for programming. The programme comprises at present 179 data fields and is subdivided on the input side into: data on anamnesis and partus, course of puerperium, infant data. This gives the print-outs: birth protocol, adhesive labels for the temperature curves of the mother and of the infant, respectively, birth record book and mother-infant health passport, furthermore, list print-outs: infant record book, transferred/decreased infants, birth lists relating to midwives, and, in addition, physician's report on the mother and the child, and finally, automated monthly and annual statistics. From August 1990 to July 1992, all events were stored by the computer, so that a total of 5,572 data items have been recorded to date. The primary scope of recording was 98.4% already in the first year of full operation of the database. Computer feed-in was affected directly after each data item became available. Application is fully integrated into normal clinical everyday work. To ensure best possible motivation and acceptance, special attention was paid to user friendliness and immediate print-outs whenever required. Attention was also given to the inclusion of infant follow-up data. The computer programme has been accepted for daily operation, and the necessary data quality has been attained by means of proper choice of the appropriate user groups and manifold measures to ensure integration, safe working, continual servicing and creation of suitable working and data feed conditions.

Attitude to Computers↗
PubMed2003

Textual content, health problems and diagnostic codes in electronic patient records in general practice.

OBJECTIVE: To investigate textual content, health problems and diagnostic codes in everyday electronic patient records. DESIGN: Retrospective and observational database study. SETTING: Primary health care in Stockholm. SUBJECTS: Twenty randomly selected general practitioners with 20 records each. MAIN OUTCOME MEASURES: The frequency of use of problem-oriented medical records. The number of words, problems and diagnostic codes. The completeness and correctness of the diagnostic codes. RESULTS: About 14.5% of 400 studied records were problem-oriented. The mean number of words per record was 99.4, and the mean number of problems managed per record was 1.2. On average, there were 1.1 diagnostic codes per record and this differed widely among GPs and also among the electronic patient record systems. The mean number of codes per problem was 0.9, and the proportion of correct codes was 97.4%. CONCLUSIONS: The electronic patient records in general practice in Stockholm have an extensive textual content. A vast majority of the problems are coded and the completeness and correctness of diagnostic codes are high. It seems that problem-oriented electronic patient record systems enforce coding activities. It is feasible to establish a database of diagnostic data for research and health care planning based on electronic patient records.

Disease↗
PubMed1994

Information management in primary medical care in South Australia.

The objectives of this study were to describe how GPs in South Australia manage and use office and clinical information, as well as their plans for the future. The study was set in a primary medical care centre in South Australia, and used a cross-sectional study with a mail questionnaire. Utilization of and satisfaction with office and clinical information management systems, with a focus on the use of patient summaries were outcome measures. A random sample was obtained from a register of GPs in South Australia that had been stratified into geographic regions based on socioeconomic indicators. Sixty-eight per cent of GPs approached responded (n = 315). There was no significant difference in response rate from each region. The use of computer applications was comparable to that in the general population. Half the GPs used index cards and 5% used computer-based records. Users of RACGP problem-oriented A4 folders were most (92%) and index card users least (65%) satisfied. The use of patient summaries could be improved. GPs planned to change to computer-based billing, more comprehensive paper-based records and computer-based patient records. Perceived reasons for and obstacles to change were documented. Factors that influenced the use of different forms of office and clinical information management were type and place of practice, staff employed, gender, a diploma in obstetrics, age, year of graduation, type of record used and satisfaction with it, vocational registration, FRACGP and FMP training. Given the pattern of utilization, generally low satisfaction and planned changes, there is an unmet need for useful office and clinical information management systems in general practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Evolution of the medical record format during two years' use of an open-format microcomputer charting system.

In 1988, the authors implemented a microcomputer charting system (SmartChart) within a busy dialysis unit and an outpatient dialysis practice, to be used as the primary recording instrument for physicians and nurses. The program defined the organization of the medical record as three types of titles: problems, therapies, and numerics. Each title had a variety of associated data, such as comments, dosages, values and normals. Predefined care plans were created, and keyboard entry was in a completely open format. Over the next two years, the overall format of this medical record proved to be highly effective, and strict problem orientation allowed both nurses and physicians to use the same problem list. A more specific organization of the title lists in the medical record was needed, however. Separate symbols were placed in front of: problem titles related to prior therapies; problems recorded during current therapies; History and Physical (H&P) data; Plans/Orders; and inactive problems. PRN therapies, those therapies related to patient treatments, vital signs, and numeric data recorded during treatments were identified. The basic format of the medical record that evolved has proven suitable for outpatient, inpatient, and specialized treatment centers.

Attitude to Computers↗
PubMedDate not supplied

The granularity of medical narratives and its effect on the speed and completeness of information retrieval.

OBJECTIVE: Using electronic rather than paper-based record systems improves clinicians' information retrieval from patient narratives. However, few studies address how data should be organized for this purpose. Information retrieval from clinical narratives containing free text involves two steps: searching for a labeled segment and reading its content. The authors hypothesized that physicians can retrieve information better when clinical narratives are divided into many small, labeled segments ("high granularity"). DESIGN: The study tested the ability of 24 internists and 12 residents at a teaching hospital to retrieve information from an electronic medical record--in terms of speed and completeness--when using different granularities of clinical narratives. Participants solved, without time pressure, predefined problems concerning three voluminous, inpatient case records. To mitigate confounding factors, participants were randomly allocated to a sequence that was balanced by patient case and learning effect. RESULTS: Compared with retrieval from undivided notes, information retrieval from problem-partitioned notes was 22 percent faster (statistically significant), whereas retrieval from notes divided into organ systems was only 11 percent faster (not statistically significant). Subdividing segments beyond organ systems was 13 percent slower (statistically significant) than not subdividing. Granularity of medical narratives affected the speed but not the completeness of information retrieval. CONCLUSION: Dividing voluminous free-text clinical narratives into labeled segments makes patient-related information retrieval easier. However, too much subdivision slows retrieval. Study results suggest that a coarser granularity is required for optimal information retrieval than for structured data entry. Validation of these conclusions in real-life clinical practice is recommended.

Cross-Over Studies↗
PubMed1991

Use of primary health care in Spili, Crete, and in Dalby, Sweden.

A computerized medical record system was introduced in Greek primary health care (PHC) in the village of Spili in Crete. The present study was carried out to study similarities and differences in the pattern of PHC use in Dalby Health Centre, Sweden (DHC), and Spili Health Centre, Greece (SHC). In both Dalby and Spili more than half the population contacted their respective health centre during 1989. Patients contacted DHC more often than SHC, 3.33 vs 2.30 times. Relatively more females than males used the health services in Dalby (64% vs 50%) but not in Spili (57% vs 55%). More visits were made by appointment at DHC than SHC (36.0% vs 12.6%). There were great similarities in the two areas in the ten most common diagnoses, analysed in four age-groups. In both areas, acute upper respiratory infections dominated in the youngest age-groups, and hypertension and diabetes in those aged 45 years and above.

Adolescent↗
PubMed1998

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Abstracting and Indexing↗
PubMed1998

The role of compositionality in standardized problem list generation.

Compositionality is the ability of a Vocabulary System to record non-atomic strings. In this manuscript we define the types of composition, which can occur. We will then propose methods for both server based and client-based composition. We will differentiate the terms Pre-Coordination, Post-Coordination, and User-Directed Coordination. A simple grammar for the recording of terms with concept level identification will be presented, with examples from the Unified Medical Language System's (UMLS) Metathesaurus. We present an implementation of a Window's NT based client application and a remote Internet Based Vocabulary Server, which makes use of this method of compositionality. Finally we will suggest a research agenda which we believe is necessary to move forward toward a more complete understanding of compositionality. This work has the promise of paving the way toward a robust and complete Problem List Entry Tool.

Humans↗
PubMed1999

Embedding guidelines into direct physician order entry: simple methods, powerful results.

Kaiser Permanente in the Northwest Region has implemented a comprehensive outpatient computer-based patient record (CPR). Using this system, clinicians electronically order laboratory tests, radiology tests, and prescriptions. Clinicians also use this comprehensive CPR to document encounters, code diagnoses and procedures, maintain problem lists, and to send patient-specific messages and referrals to other medical providers. Healthcare for our entire membership of 440,000 covered lives is now provided through this system [1]. Implementation of a comprehensive CPR with direct physician order-entry provides the opportunity to embed guidelines into the ordering process. This article describes the underlying theme and various simple but effective methods we use to embed guidelines into the ordering process. Our experience demonstrates the powerful effect of these simple methods to reduce unnecessary variation and to reduce cost while maintaining or improving the quality of care delivery.

Clinical Laboratory Techniques↗
PubMed1999

Barriers to the clinical implementation of compositionality.

BACKGROUND: Compositional mechanisms for the entry of clinically relevant controlled vocabularies have been suggested as a possible solution to providing adequate descriptive precision while keeping term vocabulary redundancy under control. As of yet, there are no widely accepted term navigators that allow physicians to enter problem lists utilizing controlled vocabularies with compositionality. METHODS: We report on the results of a usability trial of 5 physicians using our most recent attempt at developing the Mayo Problem List Manager. We tested the implementation of an automated term composition, and hierarchical term dissection. RESULTS: Participants found acceptable terms 96% of the time and found automated term composition helpful in 85% of the case scenarios. There was significant confusion about the terminology used to describe compositional elements (kernel concepts, modifiers, and qualifiers) however participants used the functions appropriately. Speed of entry was universally stated as the limiting factor. CONCLUSIONS: The variety of methods that our participants used to enter terms highlights the need for multiple ways to accomplish the task of data entry. Successful implementation of user directed compositionality could be accomplished with further improvement of the user interface and the underlying terminology.

Humans↗
PubMed1999

Influences of the Unified Service Action Model on the HL7 Reference Information Model.

Modeling information for the electronic medical record (EMR) builds on a century of study on information and its relationship to cost and quality improvement. An initiative to examine the focus of cost and quality improvement and its relationship to information modeling resulted in the development of the Unified Service Action Model of healthcare processes, which focuses on the action as the center of cost accounting, quality accounting and privacy management. The application of this model to the HL7 Reference Information Model produced a simplification of the HL7 model at the cost of increased reliance on vocabulary terms for actions.

Costs and Cost Analysis↗