[Electronic patient record. Actions and problems get a name].
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Humans↗
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Results for “Medical Records Systems, Computerized”
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An innovative approach to gathering functional requirements.
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Clinical Medicine↗
A simple approach to physician entry of patient problem list.
The patient's problem list is one of the key components of the electronic medical record. Besides the immediate benefits of using the patient problem list for medical records coding and creation of discharge documentation, a coded problem list is a prerequisite of patient management, clinical decision support and research. The ICD9 coding system that is the current standard for coding diagnoses and procedures is not conducive to physician usage. In this paper we describe a simple system that provides physicians with a quick and easy method to enter and maintain a patient's problem list. Physicians can use their own terminology. ICD9 codes are included where possible, but free text is allowed. The system strikes a balance between capturing a fully coded patient problem list and encouraging usage by a wide physician user group.
Diagnosis-Related Groups↗
The problem-oriented medical synopsis: coding, indexing, and classification sub-model.
A clinical information system consists of four major components: the clinical database, decision support, data analysis (including outcomes), and the development system. We have created such a system using generally available database methodology. The system is documented using a conceptual model, a physical model, and sub-models for individual components. A key sub-model of the clinical database, for record-keeping, has been defined for coding, indexing, and classification of the medical narrative typically encountered in medical records. We describe an approach to the development of the coding component that results in a hybrid system for recording information, locating indexed information, and summarizing it for analysis of outcomes. These are based on a primary term list--the problem glossary; SNOMed--the Systematized Nomenclature of Medicine (3rd. edition); and ICD-9-CM. The relationship with the UMLS is also discussed.
Medical Records Systems, Computerized↗
Computer tracking of multiple clinical variables in long-term treatment of heart transplant recipients.
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Computer Graphics↗
Implementation and evaluation of practice guidelines.
Practice guidelines for the management of deep vein thrombosis were implemented in a Problem-Oriented Patient Management System on the HELP Hospital Information System at the LDS Hospital. A hierarchical knowledge representation was used. The Problem-Oriented Patient Management System was designed to generate patient-specific guideline suggestions according to the clinical situation at the time of generation. A retrospective evaluation was used to compare the appropriateness of the generated guideline suggestions to the appropriateness of the attending physician's management decisions. A significantly higher proportion of guideline suggestions was evaluated to be appropriate, compared to the proportion of attending physician's management decisions found to be appropriate.
Evaluation Studies as Topic↗
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↗
Formal representation of a conceptual data model for the patient-based medical record.
We present a general architecture for the patient-based medical record as it is being developed for the SAMS, a private social security system. The conceptual data model is described in a convenient formal notation, the entity-relationship diagram. Although following the original formulation of the problem-oriented medical record (POMR), the data model was designed with a level of generalization that, functionally, makes structural differences between conventional and POMR no longer apparent. The main features of this model are its adaptability to individual work practices and its problem-oriented structure, including the representation of problems' evolution. This structure will enable physicians to organize the data, mostly collected elsewhere, by explicitly relating the facts that constitute a particular patient record, which is a simple way to store context information and clinical knowledge that is not part of patient data.
Database Management Systems↗
The Problem-Oriented Medical Synopsis: a patient-centered clinical information system.
A clinical information system consists of four major components: the clinical database, decision support, data analysis (including outcomes), and the development system. We have created such a system using generally available database methodology. The clinical database, for record-keeping, is called the Problem-Oriented Medical Synopsis, and is quite an old system, originating in 1966. We describe the suitability of a problem-oriented model of clinical records management to the relational model of database design, and describe our experience with the database as a departmental information system for patient care and outcomes research. Hybrid, or partially problem-oriented, databases represent an acceptable approach to clinical record-keeping.
Clinical Medicine↗
Dr. Welford's chart notes.
We examined a robust and highly customizable menu-based charting program created and maintained by a practicing physician. The program offers a number of well-conceived and often elegantly executed features, integrating clinically related administrative and decision-support functions at a reasonable price. The drawbacks are lack of a graphic interface with mouse support, limited importing and exporting abilities, and dependence on a single individual for maintenance of the program.
Computer Peripherals↗
OCIS: 15 years' experience with patient-centered computing.
In the mid-1970s, the medical and administrative staff of the Oncology Center at Johns Hopkins Hospital recognized a need for a computer-based clinical decision-support system that organized patients' information according to the care continuum, rather than as a series of event-specific data. This is especially important in cancer patients, because of the long periods in which they receive complex medical treatment and the enormous amounts of data generated by extremely ill patients with multiple interrelated diseases. During development of the Oncology Clinical Information System (OCIS), it became apparent that administrative services, research systems, ancillary functions (such as drug and blood product ordering), and financial processes should be integrated with the basic patient-oriented database. With the structured approach used in applications development, new modules were added as the need for additional functions arose. The system has since been moved to a modern network environment with the capacity for client-server processing.
Artificial Intelligence↗
[The circulating occupational medical record in the county of Roskilde].
The aim of the circulating occupational medical record (COMR) is to coordinate activities and documents concerning the patient who has an occupational disease. This new case record belongs to the patient, which solves the problems concerning the professional secrecy of the involved authorities. The general practitioner, the trade union and amongst others the safety organisation of the work place all have their own schematic pages in the record. The number and use of COMRs were studied. Postal questionnaires were sent to the primary users of the COMRs. Altogether 345 COMRs were started over the two year period 1989-1991. Two hundred and ninety-eight COMRs were evaluable. The page of the general practitioner was used in 90% of the records, versus 64% in the case of the unionpage and 21% in the case of the safety organisation. In 78% there were documents from medical specialists, psychologists or physiotherapists. The majority of the documents were from the department of occupational medicine. In half of the COMRs there were documents from more than four different sources. Only 76% of the patients were referred to the department of occupational medicine. It is recommended that the COMR should be extended to the whole country.
Denmark↗
A comparison of problem lists generated by physicians, nurses, and patients: implications for CPR systems.
Using a sample of 201 patients hospitalized for Pneumocystis carinii pneumonia, this study describes problem lists generated by physicians and examines the overlap among problem lists generated by physicians, nurses, and patients. The findings indicate that the majority of patients in this sample had at least one problem that occurred in more than one problem list. Problems that most frequently appeared in more than one problem list were those related to the medical diagnosis of Pneumocystis carinii pneumonia and its associated physiological symptoms. Problems which occurred uniquely in the nurse problem list were knowledge deficit and potential for injury. Thirty-four percent of the patients identified at least one psychosocial problem that did not occur in either the physician- or nurse-generated problem lists. The study findings demonstrate that while there is overlap among the problem lists in problems related to the principal medical diagnoses, the nurse- and patient-generated problem lists include unique problems which provide additional significant information related to patient status that has the potential to impact patient outcomes. These findings suggest that a unified, nonredundant, multidisciplinary problem list is warranted in order to provide a comprehensive view of the patient for computer-based patient record (CPR) systems. Appropriate data models and comprehensive controlled vocabularies are needed to support the multiple uses of the problem list for CPR systems.
Humans↗
Representation of clinical problem assessment phrases in U.S. family practice using Read version 3.1 terms: a preliminary study.
The Read Codes from the United Kingdom are a comprehensive clinical vocabulary, and one of the most likely candidates for adoption as a standard for use in Computer-Based Patient Record (CPR) systems. The new version 3.1 codes represent a major enhancement to the content and structure of the coding system, including incorporation of a new hierarchy and an explicit model for the use of qualifier terms. This is a preliminary study investigating the suitability of these codes for representing clinical problem assessment phrases in U.S. family practice. Problem assessment phrases from outpatient progress notes were encoded into the equivalent Read terms. The problem assessment phrases were evaluated for complexity and clarity. The coded representations of the phrases were evaluated for clinical acceptability. A list of coding difficulties was compiled. The most common difficulties were (1) qualifier terms present but not allowable for that Read concept (24%), and (2) qualifier terms not present (20%). British spelling and abbreviation variants were noted, but were relatively insignificant. The Read codes appear to be suitable for use in U.S. primary care practice with fairly minor modifications, but further development is required to expand the content and structure of the model for qualifier terms.
Family Practice↗
Health record problem-oriented information system.
Health Record refers to the recording of the medical and relevant social history of the patient, obtained directly or indirectly. It is an instrument of frequent use that must guarantee the quality of assistance provided, reflecting all information pertinent to forming the patient's medical history. It must be designed so that data is easily and effectively retrieved for everyday use, without compromising the patient's privacy. The Health Record Problem Oriented model achieves all of these objectives. This model comprises: 1. Initial data: the relevant medical histories and biography is recorded. 2. Problems list: the patient provides reasons why she is seeking medical attention. 3. Performance plans: these include diagnostic, therapeutic, pharmacological, dietetic, physiotherapist, and surgical plans, as well as the education of the patient. 4. Evolution notes: the progress of the condition. This model guarantees multi-professional registration, an integral focus on the health, and a continued focus on the patient. These characteristics make it the model par excellence of Primary Care. Prior to the implementation of this model, existing information must be analyzed so that it can eventually be converted to a relational database. The Entity-Relationship Model (E/R Model) has been used to represent the database. Here, the basic concepts involved are entities, relationships, and attributes. Entities represent classes or objects from the real world that have common characteristics. The relationships represent the aggregation of two or more entities. The attributes are elemental properties of both entities and relationships. The E/R Diagram graphically represents the conceptual model of a database; the one built for the Health Record Problem Oriented reflects all the entities that compound the attending processes and the relationships existing between them. The Patient is the central axis of the attending process. The record contains the identifying data of the subject and his habits. We can know his medical history by means of his past Illness (personal and family record), Vaccine (what he is vaccinated against), and Case History (each patient has a case history). The other important component is the Consult Motive. A patient has a reason for every consultation, and this reason is added to her medical history as part of the Consult Motive. Each consult motive produces different events that are shown as relations with the other entities. So, for example, by analyzing a patient's history of complaints, a doctor can more suitably determine if she should recommend Cardiac or Anthropometric Exploration, request an Analysis, request a Radiography or Specialist Report, or prescribe a Treatment. The various elements that are part of a Consult Motive are expressed as different entities. Once the conceptual schema of the database is defined, the next step is to convert this schema to a logical schema, suitable for the Relational Model.
Medical Records Systems, Computerized↗
Seven years experience with a computerized diabetes clinic database.
With the emergence of information technology applications in medicine, a computerized medical record system that could be used to : (1) maintain patients' clinical records over time, (2) communicate with referring practitioners, and (3) form the basis of a potential research database of information, was sought. In 1987, we developed such a clinical database to register patients attending our busy Diabetes Clinic, now seeing in excess of 300 new referrals and, on average, 3,000 clinic visits per year. Baseline demographic data, clinical history, and examination and investigation results are recorded. We also record diabetes therapy and other medication dosage and changes, monitor follow-up, assess health outcome information (such as stroke or amputation), and generate results, summaries, and reports to referring practitioners and other health professionals. We now have almost seven years of experience using the system. Initially established on a single PC with paper-based data collection and subsequent data entry (running as a DOS application), it is now established on a PC Local Area Network [LAN] with terminals in the clinic consultation rooms enabling direct data entry and allowing patients to view their results in graphic form on screen. From its inception, the Diabetes Clinic Database System has maintained patient demographic and clinical data (which facilitates efficient clinic management) with patient clinic lists and adhesive address labels generated from appropriate menus. Batch mode processing produces daily work sheets which facilitate the running of clinics as well as ad hoc, daily, and weekly reports for all patients (as required). This expedites correspondence with referring doctors. A quality assurance report to the clinic doctor highlights missing clinical information which must be obtained in order to ensure data completeness. The initial system was relatively inefficient in that it required data entry following patient consultation and provided no immediate feedback to patients themselves. In January 1994, to address these deficiencies, the system was established on a PC LAN (running under Novell); it provided on-line data entry within the clinic setting and enabled patients to participate in the recording of their information, observe their own progress by way of on-screen graphs (e.g., blood sugar control, weight, cholesterol), and receive hand-held summaries generated immediately following the clinic visit. Batch programs generate hard copies of this data to be filed in medical records. Two major assessments of the system have been undertaken. In February 1990, we undertook a survey of Local Doctors with 5 or more patient referrals on the system; this resulted in a pleasing 66% response rate. There was an almost universal acceptance and indeed a significant preference for this system over 'traditional' letters. In January 1994, following the introduction of the system onto the PC LAN for direct data entry in the clinic setting, we assessed (by anonymous questionnaire at the end of the consultation) patient attitudes towards these changes. The development of the CRS Diabetes Clinic Database System has improved our approach to diabetes outpatient care and our communication with other health professionals. It has the added benefit of providing a database of information that is suitable to address critical clinical research issues in diabetes management. This system provides an acceptable blend of information technology and clinical medicine, redesigning and enhancing the way we deliver medical care to patients with diabetes. Involving the patient in the collection and interpretation of their clinical data via a computer system (as utilized within our clinical unit), is both acceptable to the patient and her referring doctor. Ongoing system refinement and assessment remains integral to our use of information technology.
Australia↗
A standards-based clinical information system for HIV/AIDS.
OBJECTIVE: To create a clinical data repository to interface the Veteran's Administration (VA) Decentralized Hospital Computer Program (DHCP) and a departmental clinical information system for the management of HIV patients. This system supports record-keeping, decision-making, reporting, and analysis. The database development was designed to overcome two impediments to successful implementations of clinical databases: (i) lack of a standard reference data model, and; (ii) lack of a universal standard for medical concept representation. BACKGROUND: Health Level Seven (HL7) is a standard protocol that specifies the implementation of interfaces between two computer applications (sender and receiver) from different vendors or sources of electronic data exchange in the health care environment. This eliminates or substantially reduces the custom interface programming and program maintenance that would otherwise be required. HL7 defines the data to be exchanged, the timing of the interchange, and the communication of errors to the application. The formats are generic in nature and must be configured to meet the needs of the two applications involved. The standard conceptually operates at the seventh level of the ISO model for Open Systems Interconnection (OSI). The OSI simply defines the data elements that are exchanged as abstract messages, and does not prescribe the exact bit stream of the messages that flow over the network. Lower level network software developed according to the OSI model may be used to encode and decode the actual bit stream. The OSI protocols are not universally implemented and, therefore, a set of encoding rules for defining the exact representation of a message must be specified. The VA has created an HL7 module to assist DHCP applications in exchanging health care information with other applications using the HL7 protocol. The DHCP HL7 module consists of a set of utility routines and files that provide a generic interface to the HL7 protocol for all DHCP applications. SETTING: The VA's DHCP core modules are in standard use at 169 hospitals, and the role of the VA system in health care delivery has been discussed elsewhere. This development was performed at the Miami VA Medical Center Special Immunology Unit, where a database was created for an HIV patient registry in 1987. Over 2,300 patient have been entered into a database that supports a problem-oriented summary of the patient's clinical record. The interface to the VA DHCP was designed and implemented to capture information from the patient treatment file, pharmacy, laboratory, radiology, and other modules. RESULTS: We obtained a suite of programs for implementing the HL7 encoding rules from Columbia-Presbyterian Medical Center in New York, written in ANSI C. This toolkit isolates our application programs from the details of the HL7 encoding rules, and allows them to deal with abstract messages and the programming level. While HL7 has become a standard for healthcare message exchange, SQL (Structured Query Language) is the standard for database definition, data manipulation, and query. The target database (Stitt F.W. The Problem-Oriented Medical Synopsis: a patient-centered clinical information system. Proc 17 SCAMC. 1993:88-93) provides clinical workstation functionality. Medical concepts are encoded using a preferred terminology derived from over 15 sources that include the Unified Medical Language System and SNOMed International ( Stitt F.W. The Problem-Oriented Medical Synopsis: coding, indexing, and classification sub-model. Proc 18 SCAMC, 1994: in press). The databases were modeled using the Information Engineering CASE tools, and were written using relational database utilities, including embedded SQL in C (ESQL/C). We linked ESQL/C programs to the HL7 toolkit to allow data to be inserted, deleted, or updated, under transaction control. A graphical format will be used to display the entity-rel
Acquired Immunodeficiency Syndrome↗
Automated classification of encounter notes in a computer based medical record.
Harvard Community Health Plan is exploring emerging information technologies for means to use the text portion of its 25 year old computerized medical record system. The Center for Intelligent Information Retrieval is developing systems to answer the question: to what extent can automated information systems replace manual chart review of encounter notes? INQUERY, a probabilistic inference net information retrieval system, and FIGLEAF, an inductive decision tree text classifier are applied to the problem of classifying electronic encounter notes to identify acute exacerbations in pediatric asthmatics. Both systems achieve average precisions of greater than 80%, with a new enhancement to INQUERY's relevance feedback, the top performer. Refinement of the systems and plans for their integration are discussed.
Asthma↗