Reliability of trauma coding with ICD-10 / 中华创伤杂志(英文版)

PURPOSE@#The reliability of trauma coding is essential in establishing the reliable trauma data and adopting efficient control and monitoring policies. The present study aimed to determine the reliability of trauma coding in educational hospitals affiliated to Shahid Beheshti University of Medical Sciences, Iran.@*METHODS@#In this descriptive cross-sectional study, 591 coded medical records with a trauma diagnosis in 2018 were selected and recoded by two coders. The reliability of trauma coding was calculated using Cohen's kappa. The data were recorded in a checklist, in which the validity of the content had been confirmed by experts.@*RESULTS@#The reliability of the coding related to the nature of trauma in research units was 0.75-0.77, indicating moderate reliability. Also, the reliability of the coding of external causes of trauma was 0.57-0.58, suggesting poor reliability.@*CONCLUSION@#The reliability of trauma coding both in terms of the nature of trauma and the external causes of trauma does not have a good status in the research units. This can be due to the complex coding of trauma, poor documentation of the cases, and not studying the entire case. Therefore, holding training courses for coders, offering training on the accurate documentation to other service providers, and periodically auditing the medical coding are recommended.

Evaluation of Nursing Information Systems: Application of Usability Aspects in the Development of Systems / 대한의료정보학회지

OBJECTIVES: As the largest group providing healthcare services, nurses require well-designed information systems in their practice. This study aims to evaluate the usability of nursing information systems (NIS). METHODS: This cross-sectional survey was conducted in 2015. The settings of the study consisted of four hospitals affiliated with three medical universities in Tehran (Iran). The subjects of the study included nurses who had access to and used a NIS developed by four major software companies. The data were collected using a modified version of a usability questionnaire known as IsoMetrics, based on the International Standard ISO 9241, Part 11. The questionnaire is composed of 35 questions divided into seven general criteria. The validity of the questionnaire was determined by experts in the field, and the reliability was checked using Cronbach's alpha (α = 0.91). The questionnaire was then distributed to 184 nurses. RESULTS: The response rate was 64.6%. Among the seven ISO usability criteria, suitability for the task (3.10 ± 1.24) and suitability for learning (3.10 ± 1.27) had the highest mean value. The lowest mean value (2.37 ± 1.29) was related to the suitability for individualization. CONCLUSIONS: Addressing issues related to individualization and self-descriptiveness could improve the usability of nursing systems. Considering usability requirements in the design of a NIS will lead to the efficient and effective use of these systems.

Electronic health record architecture: a systematic review

Numerous advantages are derived from the electronic health record [EHR]. Though achieving such advantages depends on its architecture, at present no unique understanding of the architecture dimensions and specifications is available. Therefore, the aim of the present study is a systematic review of architecture perception of the electronic health record. The authors searched the literature in Science Direct, Scopus, PubMed and Proudest Databases [2000 to Jun 2015]. Data extraction was done by 2 reviewers on content, structure, content/structure relationship, confidentiality and security of the EHR. Subsequent to refining the 87 retrieved studies, 25 studies were finally included in the study. In the studies and paradigms so far proposed for the EHR, a unique comprehensive architecture model from the viewpoint of research criteria has not been investigated and it has been considered only from some dimensions. Hence, we provide a new definition of the EHR architecture

Pharmacy information systems in Tehran university hospitals and their relationship with pharmaceutical companies

Background: A pharmacy information system must retrieve process and update the information it obtains for safe and effective use of drugs. It is used to manage drug usage in the patient health care process and to communicate a large volume of information to pharmacy and pharmaceutical firms. Bearing in mind such issues, the current study adopted a descriptive method of research to investigate the pharmacy information systems in university hospitals and their relationship with pharmaceutical firms. The research data were collected through observation and interview based on a checklist and a questionnaire. Validity and reliability of the data gathering tools were specified through content validity and test re-test methods. The collected data were then analyzed, using a set of descriptive statistics. According to the results, pharmacy information systems in the hospitals under study were partially computerized. Databases for drugs, patients and prescriber databases, with different values of 50.1%, 21.9%, and 33.3% respectively, were not complete, as had been recorded in the pharmacy information system of the hospitals. The pharmacy information system is normally used to support therapeutic activities and the inventory, but such support had not been provided for 43.9 % of the hospitals. 32.2 % of the hospitals under study had not reported pharmaceutical information such as statistical data and drugs' prices. Also, 27.3% of the pharmaceutical firms did not have any relationship with pharmacy information systems. Pharmaceutical companies had developed some relationship, on marketing issues, with hospital pharmacies. The findings were in favor of further therapeutic activities by pharmacy information systems, which could be achieved by improving relationship between hospitals and pharmaceutical firms, particularly in Tehran. This could help to manage drug consumption and supervision, after marketing, in order to eliminate adverse drug reactions and develop high quality pharmaceutical services

Infrastructures of the system for developing electronic health record

The overall objective of a health system is to improve health through reducing disease, disability and death. Accomplishment of this goal depends on the worldwide integrated and coordinated care continuity. Information transmission is a prerequisite to ensure the continuity of care. Widespread acceptance of health information and communication technology [HICT] and developing systems such as Electronic Health Record [EHR], have changed the health care industry. Electronic Health Record is the main part of information management in an integrated health care system. Electronic health record provides access to all health information at organizational, regional, national and international levels and allows for the patient's health data [usually with geographical distribution in several health information systems] to become integrated. Since Electronic health record integrates all care events data, it can make data sharing possible between all care providers to consequently minimize the repeated diagnostic tests, and drug and treatment interactions. Furthermore, Also health care professionals can easily access to patient information at any time and this could lead to improving the quality of care and reduce costs. Accordingly, a productive system is required to provide the electronic health record. Given the significance of the electronic health record and its generating system in improvement of care quality and reducing the health care costs, authors decided to study the needs for developing the national EHR system [NHIN] The main focus of this paper was on selecting material related to the system developing an EHR and it prerequisites. Electronic health record system is a new source of valuable intelligence of real world for the whole health care industry. Electronic health record system includes people, rules, standards, storage and processing equipments, communication and support facilities. To shape this, existence of components and their coordination is necessary. Electronic health record system are established to enhance patient care and its outcome, increase efficiency, improving the availability of information and minimizing the medical errors. With the Europe union formation that in fact was an important step toward globalization, the electronic health record passed the national borders and turned into a global concept to make possible the worldwide integration and sharing of the health data. Therefore international standards are needed to share patient health information between national health systems and across borders. Infrastructure or national information network existence of proper hardware and software and finally participation of all stakeholders are necessary to develop the system. So it is necessary to prepare the infrastructures needed for development of the system in our country. Since EHR has a universal concept, it is needed to create a lifelong health information record for every individual accessible in every point in the world

Situation analysis of hematology information systems in educational-therapeutic hospital laboratories of Shaheed Beheshti University of Medical Sciences

Hematology section provides valuable information for diagnosis and treatment of patients to improve the health of them. In this regard Hematology Information System led to deliver produced information accurately and timely. Present study aimed to analyze the situation of Hematology Information Systems in hospital laboratories. In this descriptive study, 13 Hematology Information Systems of hospital laboratories in Shaheed Beheshti University of medical Sciences were assessed. Data were gathered through observing and questioning by checklist and questionnaire tools. The questionnaire content validity and its reliability were approved. The analysis of data was conducted based on descriptive analysis. 76.92 percent of Hematology Information Systems were semi-mechanized type and others were mechanized. Dividing data to three groups, results showed averagely patient data elements were in 79.4 percent, sample data elements in 93.85 percent, and test data elements in all of the systems. In 87.5 percent of them, processing of data was done by auto-analyzers. In all of the systems, data were gathered by request forms, labels and computers. Communication networks were not used in 76.92 percent of Hematology Information Systems. Only 15.38 percent of them used the statistical softwares for data analysis. Also, only 23.08 percent of systems were applied the communication networks. 80 percent of systems had workers of data gathering, processing and distributing. Mechanized systems can meet the users' needs better; therefore gathering, processing, and information distributing steps were done correctly