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A Template-based Approach to Support Utilization of Clinical Practice Guidelines Within an Electronic Health Record

Henry, Suzanne Bakken; Douglas, Kathy; Galzagorry, Grace; Lahey, Anne; Holzemer, William L.
Fonte: American Medical Informatics Association Publicador: American Medical Informatics Association
Tipo: Artigo de Revista Científica
Publicado em //1998 Português
Relevância na Pesquisa
25.75%
Practice guidelines are an integral part of evidence-based health care delivery. When the authors decided to install the clinical documentation component of an electronic health record in a nurse practitioner faculty practice, however, they found that they lacked the resources to integrate it immediately with other systems and components that would support the processing of clinical rules. They were thus challenged to devise an initial approach for decision support related to clinical practice guidelines that did not include interfacing with an inference engine and set of decision rules. The authors developed a prototypic application within the WAVE electronic health record that demonstrates the feasibility of representing a guideline as structured encoded text organized into an online patient-encounter template. Although this approach may be more broadly applicable, it is described within the context of the management of diabetes mellitus by nurse practitioners. The advantages of the approach relate primarily to the integration of the guideline recommendations with the encounter form, the online interaction of the clinician with the system, and the ease of creation and modification of the guideline-based encounter form. However...

Speech Language Pathology Assessments On-line Project: Small Steps Toward Electronic Clinical Documentation in a Long Term Care Facility

Miranda, Conrado; Care, Geriatric
Fonte: PubMed Publicador: PubMed
Tipo: Artigo de Revista Científica
Publicado em //2002 Português
Relevância na Pesquisa
25.75%
As the need for health information quality and distribution becomes more time critical, with greater emphasis on data integrity and security, there is increasing need to move away from the pen and paper medium toward the electronic capture and processing of data and information. At Baycrest, a centre of excellence for long-term care, this was an innovative yet intimidating concept, a reality whose time had finally arrived.

Repurposing the Clinical Record: Can an Existing Natural Language Processing System De-identify Clinical Notes?

Morrison, Frances P.; Li, Li; Lai, Albert M.; Hripcsak, George
Fonte: American Medical Informatics Association Publicador: American Medical Informatics Association
Tipo: Artigo de Revista Científica
Publicado em //2009 Português
Relevância na Pesquisa
25.79%
Electronic clinical documentation can be useful for activities such as public health surveillance, quality improvement, and research, but existing methods of de-identification may not provide sufficient protection of patient data. The general-purpose natural language processor MedLEE retains medical concepts while excluding the remaining text so, in addition to processing text into structured data, it may be able provide a secondary benefit of de-identification. Without modifying the system, the authors tested the ability of MedLEE to remove protected health information (PHI) by comparing 100 outpatient clinical notes with the corresponding XML-tagged output. Of 809 instances of PHI, 26 (3.2%) were detected in output as a result of processing and identification errors. However, PHI in the output was highly transformed, much appearing as normalized terms for medical concepts, potentially making re-identification more difficult. The MedLEE processor may be a good enhancement to other de-identification systems, both removing PHI and providing coded data from clinical text.

Data from clinical notes: a perspective on the tension between structure and flexible documentation

Rosenbloom, S Trent; Denny, Joshua C; Xu, Hua; Lorenzi, Nancy; Stead, William W; Johnson, Kevin B
Fonte: BMJ Group Publicador: BMJ Group
Tipo: Artigo de Revista Científica
Português
Relevância na Pesquisa
26.01%
Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.

Strategies for Handling Missing Data in Electronic Health Record Derived Data

Wells, Brian J.; Chagin, Kevin M.; Nowacki, Amy S.; Kattan, Michael W.
Fonte: AcademyHealth Publicador: AcademyHealth
Tipo: Artigo de Revista Científica
Publicado em 17/12/2013 Português
Relevância na Pesquisa
25.9%
Electronic health records (EHRs) present a wealth of data that are vital for improving patient-centered outcomes, although the data can present significant statistical challenges. In particular, EHR data contains substantial missing information that if left unaddressed could reduce the validity of conclusions drawn. Properly addressing the missing data issue in EHR data is complicated by the fact that it is sometimes difficult to differentiate between missing data and a negative value. For example, a patient without a documented history of heart failure may truly not have disease or the clinician may have simply not documented the condition. Approaches for reducing missing data in EHR systems come from multiple angles, including: increasing structured data documentation, reducing data input errors, and utilization of text parsing / natural language processing. This paper focuses on the analytical approaches for handling missing data, primarily multiple imputation. The broad range of variables available in typical EHR systems provide a wealth of information for mitigating potential biases caused by missing data. The probability of missing data may be linked to disease severity and healthcare utilization since unhealthier patients are more likely to have comorbidities and each interaction with the health care system provides an opportunity for documentation. Therefore...

Examining the Use, Contents, and Quality of Free-Text Tobacco Use Documentation in the Electronic Health Record

Chen, Elizabeth S.; Carter, Elizabeth W.; Sarkar, Indra Neil; Winden, Tamara J.; Melton, Genevieve B.
Fonte: American Medical Informatics Association Publicador: American Medical Informatics Association
Tipo: Artigo de Revista Científica
Publicado em 14/11/2014 Português
Relevância na Pesquisa
25.86%
Recent initiatives have emphasized the potential role of Electronic Health Record (EHR) systems for improving tobacco use assessment and cessation. In support of these efforts, the goal of the present study was to examine tobacco use documentation in the EHR with an emphasis on free-text. Three coding schemes were developed and applied to analyze 525 tobacco use entries, including structured fields and a free-text comment field, from the social history module of an EHR system to characterize: (1) potential reasons for using free-text, (2) contents within the free-text, and (3) data quality issues. Free-text was most commonly used due to limitations for describing tobacco use amount (23.2%), frequency (26.9%), and start or quit dates (28.2%) as well as secondhand smoke exposure (17.9%) using a variety of words and phrases. The collective results provide insights for informing system enhancements, user training, natural language processing, and standards for tobacco use documentation.

National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: exploratory qualitative investigation

Morrison, Zoe; Fernando, Bernard; Kalra, Dipak; Cresswell, Kathrin; Sheikh, Aziz
Fonte: BMJ Publishing Group Publicador: BMJ Publishing Group
Tipo: Artigo de Revista Científica
Português
Relevância na Pesquisa
35.98%
Objective: We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs). Materials and methods Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics. Results: Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients. Conclusions: The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive...

How do experienced Information Lens users use rules?

Fonte: Center for Information Systems Research, Massachusetts Institute of Technology, Sloan School of Management Publicador: Center for Information Systems Research, Massachusetts Institute of Technology, Sloan School of Management
Formato: 12 p.; 887747 bytes; application/pdf
Português
Relevância na Pesquisa
45.75%
Wendy E. Mackay ... [et. al.].; "October 1988."; Includes bibliographical references (p. 12).

Maldives : Electronic Government Procurement Readiness Assessment and Roadmap

World Bank
Fonte: Washington, DC Publicador: Washington, DC
Tipo: Economic & Sector Work :: Other Procurement Study; Economic & Sector Work
Português
Relevância na Pesquisa
35.98%
The assessment focuses on the degree of readiness of Government of The Maldives's (GoTM's) current public procurement environment for making a transition from traditional paper-based, manual methods of procurement transaction processing and communication to electronic government procurement (e-GP). The e-GP Assessment was discussed individually with informed respondents in the public and private sectors, who provided advice or comment on the degree of readiness of nine key components related to e-GP: government leadership, human resource planning, procurement planning and management, procurement policy, procurement legislation and regulation, Internet and electronic infrastructure, standards, private sector integration, and current e-GP systems and initiatives. The assessment found: adequate evidence that Internet and electronic infrastructure are in place and supported, little evidence that government leadership, planning and management, procurement regulation, standards, private sector integration, or e-GP systems are in place and being supported; no evidence that human resource planning...

Trading Up : How Tunisia Used ICT to Facilitate Trade

Alavi, Hamid
Fonte: World Bank, Washington, DC Publicador: World Bank, Washington, DC
Tipo: Publications & Research :: Brief; Publications & Research
Português
Relevância na Pesquisa
25.96%
Although trade liberalization can create jobs and raise incomes, these benefits are easily undermined if excessive costs and delays hinder trade transactions - reducing a country's export competitiveness. This note shows how Tunisia embraced information and communications technology (ICT) to facilitate trade - cutting costs, saving time, and increasing international competitiveness. It also highlights the context and challenges, key initiatives, success factors, and impact of Tunisia's efforts. Trade clearances can improve dramatically when administrative and political commitment combines with advances in information and communications technology.

Documentation

Surveillance Studies Centre
Fonte: Surveillance Studies Centre Publicador: Surveillance Studies Centre
Tipo: Dataset; Technical Report
Português
Relevância na Pesquisa
35.73%
The Globalization of Personal Data (GPD) was an international, multi-disciplinary and collaborative research initiative drawing mainly on the social sciences but also including information, computing, technology studies and law, that explored the implications of processing personal and population data in electronic format from 2004 to 2008. Such data included everything from census statistics to surveillance camera images, from biometric passports to supermarket loyalty cards. The project maintained a strong concern for ethics, politics and policy development around personal data. The project, funded by the Social Sciences and Humanities Research Council of Canada (SSHRCC) under its Initiative on the New Economy program, conducted research on why surveillance occurs, how it operates, and what this means for people's everyday lives (See http://www.sscqueens.org/projects/gpd). The unique aspect of the GPD included a major international survey on citizens' attitudes to issues of surveillance and privacy.; There are three data files in this study. The first covers the original 7 countries surveyed in 2006 (Canada, USA, France, Spain, Hungary, Mexico, and Brazil), and the other two cover China (surveyed in 2006) and Japan (surveyed in 2007).; Social Sciences and Humanities Research Council of Canada (SSHRCC)

Derived Data Storage and Exchange Workflow for Large-Scale Neuroimaging Analyses on the BIRN Grid

Keator, David B.; Wei, Dingying; Gadde, Syam; Bockholt, Jeremy; Grethe, Jeffrey S.; Marcus, Daniel; Aucoin, Nicole; Ozyurt, Ibrahim B.
Fonte: Frontiers Research Foundation Publicador: Frontiers Research Foundation
Tipo: Artigo de Revista Científica
Publicado em 07/09/2009 Português
Relevância na Pesquisa
35.74%
Organizing and annotating biomedical data in structured ways has gained much interest and focus in the last 30 years. Driven by decreases in digital storage costs and advances in genetics sequencing, imaging, electronic data collection, and microarray technologies, data is being collected at an ever increasing rate. The need to store and exchange data in meaningful ways in support of data analysis, hypothesis testing and future collaborative use is pervasive. Because trans-disciplinary projects rely on effective use of data from many domains, there is a genuine interest in informatics community on how best to store and combine this data while maintaining a high level of data quality and documentation. The difficulties in sharing and combining raw data become amplified after post-processing and/or data analysis in which the new dataset of interest is a function of the original data and may have been collected by multiple collaborating sites. Simple meta-data, documenting which subject and version of data were used for a particular analysis, becomes complicated by the heterogeneity of the collecting sites yet is critically important to the interpretation and reuse of derived results. This manuscript will present a case study of using the XML-Based Clinical Experiment Data Exchange (XCEDE) schema and the Human Imaging Database (HID) in the Biomedical Informatics Research Network's (BIRN) distributed environment to document and exchange derived data. The discussion includes an overview of the data structures used in both the XML and the database representations...

Using Provenance to support Good Laboratory Practice in Grid Environments

Ney, Miriam; Kloss, Guy K.; Schreiber, Andreas
Fonte: Universidade Cornell Publicador: Universidade Cornell
Tipo: Artigo de Revista Científica
Publicado em 13/12/2011 Português
Relevância na Pesquisa
16.02%
Conducting experiments and documenting results is daily business of scientists. Good and traceable documentation enables other scientists to confirm procedures and results for increased credibility. Documentation and scientific conduct are regulated and termed as "good laboratory practice." Laboratory notebooks are used to record each step in conducting an experiment and processing data. Originally, these notebooks were paper based. Due to computerised research systems, acquired data became more elaborate, thus increasing the need for electronic notebooks with data storage, computational features and reliable electronic documentation. As a new approach to this, a scientific data management system (DataFinder) is enhanced with features for traceable documentation. Provenance recording is used to meet requirements of traceability, and this information can later be queried for further analysis. DataFinder has further important features for scientific documentation: It employs a heterogeneous and distributed data storage concept. This enables access to different types of data storage systems (e. g. Grid data infrastructure, file servers). In this chapter we describe a number of building blocks that are available or close to finished development. These components are intended for assembling an electronic laboratory notebook for use in Grid environments...

Cary collection web presentation & digital image database

McCombe, Cynthia
Fonte: Rochester Instituto de Tecnologia Publicador: Rochester Instituto de Tecnologia
Tipo: Tese de Doutorado
Português
Relevância na Pesquisa
35.74%
The Melbert Cary, Jr. Graphic Arts Collection in the Wallace Memorial Library is one of the treasures the RIT community has had available for years. For this thesis project, selected materials from the collection were scanned and made available on the Internet so people at any location can experience the rare and invaluable items the facility houses. Not only has the result of this project created an educational tool for others to use, but it also challenged the author to master web publishing while developments rapidly occur on the most powerful mass communications media to arise in decades. While the primary purpose of this thesis project was to create an aesthetically pleasing and information rich web presentation for the Melbert Cary, Jr. Graphic Arts Collection, many secondary goals had to first be achieved. Those secondary goals are outlined in this list: 1. To acquire high quality color electronic images for others to access remotely. 2. To design a searchable database of 300 records. 3. To learn the ins-and-outs of web publishing by: Creating cohesive and consistent documents in the HyperText Markup Language (HTML). Developing an aesthetically pleasing interface for users to explore documents. This included keeping up-to-date with developments in HTML and using techniques created by web publishing experts to make the text as typographically pleasing as possible. Placing the necessary documents and images on a web server. Advertising the address of the presentation...

Transforming Data Into Information: The Development and Demonstration of a Model to Support Transportation Planning

Racca, David P.
Fonte: Center for Applied Demography & Survey Research Publicador: Center for Applied Demography & Survey Research
Tipo: Outros Formato: 2194028 bytes; application/pdf
Português
Relevância na Pesquisa
45.8%
In this project a functional prototype of web based documentation, search, cataloging, and organizational tool was created to demonstrate a potentially powerful aid to the Division of Planning. For purposes of discussion this utility will be termed the DUROS, the Documentation Utility for Referencing, Organization, and Search. In conclusion, DUROS represents a simple but powerful utility that can be developed and implemented in the near term with relatively low cost when compared to large scale data warehouse efforts.

Hybrid data capture for monitoring patients on highly active antiretroviral therapy (HAART) in urban Botswana

Bussmann,Hermann; Wester,C William; Ndwapi,Ndwapi; Vanderwarker,Chris; Gaolathe,Tendani; Tirelo,Geoffrey; Avalos,Ava; Moffat,Howard; Marlink,Richard G
Fonte: World Health Organization Publicador: World Health Organization
Tipo: Artigo de Revista Científica Formato: text/html
Publicado em 01/02/2006 Português
Relevância na Pesquisa
45.79%
Individual patient care and programme evaluation are pivotal for the success of antiretroviral treatment programmes in resource-limited countries. While computer-aided documentation and data storage are indispensable for any large programme, several important issues need to be addressed including which data are to be collected, who collects it and how it is entered into an electronic database. We describe a patient-monitoring approach, which uses patient encounter forms (in hybrid paper + electronic format) based on optical character recognition, piloted at Princess Marina Hospital in Gaborone, Botswana's first public highly active antiretroviral therapy (HAART) outpatient clinic. Our novel data capture approach collects "key" data for tracking patient and programme outcomes. It saves physician time and does not detract from clinical care.