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La elaboración del expediente clínico es una actividad rutinaria dentro del consultorio dental, éste es la materialización del acto médico, a tra- vés del cual se registra el estado de salud inicial del paciente, así como toda la información relativa al tratamiento recibido. Desde hace algunos años comenzó a promocionarse el expediente clínico electrónico como una herramienta alternativa y novedosa para elaborar este importante documento; sin embargo, la implementación de esta herramienta electrónica no ha podido lograrse en México, dada la gran cantidad de dudas que los odontólogos tienen respecto al conjunto de leyes y normas que regulan al expediente clínico, lo cual genera renuencia por parte de los odontólogos para utilizar esta modalidad de expediente dentro de su consulta diaria. El objetivo del presente artículo es realizar una revisión de la literatura, así como de las leyes y normas vigentes que regulan el expediente clínico en México para esclarecer así la viabilidad de implementarlo dentro del consultorio dental
The preparation of the electronic medical record is a routine activity in the dental office, this is the materialization of the medical act, through which the initial health status of the patient is recorded, as well as all the information related to the received treatment. A few years ago, the electronic clinical record began to be promoted as a novel alternative tool to prepare this important document, however, the implementation of this electronic tool has not been achieved in Mexico, given the large number of doubts that dentists have regarding the set of laws thar regulate the clinical record, which generates reluctance on the part of dentists to use this record modality within their daily consultation. The aim of this article is to carry out a review of the literature, as well as the current laws that regulate the clinical record in Mexico, in order to clarify the feasibility of implementing it within the dental office
Subject(s)
Humans , Clinical Record , Dental Records/legislation & jurisprudence , Electronic Health Records/legislation & jurisprudence , Legislation, Dental/standards , MexicoABSTRACT
Objective:To develop and test a software which can get and count the medical exposure frequency automatically.Methods:This study was based on the investigation of the frequency of radiodiagnostic medical procedures in China over the past by reference to the experience gained from the Electronic Medical Record Sharing and Reporting System in Beijing. The core elements for collecting the number of medical procedures and radiodiagnostic categories were determined. The collection process was then designed and the collection program software was written in a way for deployment on the front-end computer system of a general hospital for trial.Results:The field table to collect the number of medical procedures and the corresponding data structure were generated, and the data collection and statistics of the above fields were realized based on the survey data of DR and CT diagnostic examination frequency in a hospital in 2021. It took 15 s on average, and the statistical result are consistent with the manual statistical result using RIS source table.Conclusions:The software can realize the automatic acquisition and reporting of the number of radiodiagnostic medical procedures in hospital on a regular basis, which is worth promoting.
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Resumo Como parte do estudo de avaliabilidade da avaliação da implementação do Prontuário Eletrônico do Paciente (PEP), o objetivo desta Revisão Sistemática (RS) foi identificar os domínios de avaliação a serem abordados. Esta RS, alinhada com o Cochrane Handbook for Systematic Reviews of Interventions e o Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) englobou artigos publicados de 2006 até 2019. Realizou-se a busca nas bases de dados eletrônicas SciELO, Oásis IBICT, BVS Regional e Scopus. A busca retornou 1.178 artigos, sendo 42 que atenderam aos critérios de inclusão. A maioria dos estudos utilizaram métodos qualitativos para análises. As publicações ocorreram entre 2006 e 2019, tendo sua concentração em 2017 com 9 (21%) artigos publicados. Não foram identificados estudos publicados em 2008 e 2009. Somente 10 estudos incluíam descrição, análises ou resultados relacionados aos domínios de implementação. Os principais domínios em que o PEP foi problematizado foram: subutilização; resistência dos profissionais ao seu uso; ênfase na usabilidade; e o PEP como repositório de informações. Apesar da inclusão de todos os estudos que contemplaram os princípios e diretrizes da Política Nacional de Humanização (PNH), eles ainda são incipientes.
Abstract As part of the evaluability study of the implementation of the Electronic Patient Record (EPR) evaluation, the aim of this Systematic Review (SR) was to identify the evaluation domains to be addressed. This SR, aligned with the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) encompassed articles published from 2006 to 2019. The search was carried out in the electronic databases SciELO, Oasis IBICT, BVS Regional and Scopus. The search resulted in 1,178 articles, 42 of which met the inclusion criteria. Most studies used qualitative methods for the analyses. The publications took place between 2006 and 2019, with a concentration in 2017 with 9 (21%) articles published in that year. No studies were published in 2008 and 2009. Only 10 studies included the description, analysis or results related to the domains of implementation. The main domains in which the EPR was problematized were: underutilization; professionals' resistance to its use; emphasis on usability; and EPR as an information source. Despite the inclusion of all studies that covered the principles and guidelines of the National Humanization Policy (NHP), they are still incipient.
Subject(s)
Humans , Primary Health Care , Humanization of Assistance , Electronic Health Records , Unified Health SystemABSTRACT
La digitalización de la historia clínica, documento indispensable en la atención de salud y que posee carácter legal, es uno de los focos de atención en la e-Salud. El sistema XAVIA HIS compuesto por módulos que informatizan los procesos e interconectan las diferentes áreas de una institución hospitalaria, posee como atributo fundamental, una historia clínica electrónica única por paciente. Esta se compone por documentos basados en el estándar HL7-CDA. Sin embargo, el sistema XAVIA HIS presenta algunas limitantes en la interacción con otras aplicaciones que gestionen la información de salud. En el trabajo se presentan las modificaciones a realizar al Sistema de Información Hospitalaria XAVIA HIS para mejorar la capacidad de gestión de las historias clínicas electrónicas del sistema. Se realizó un análisis de la literatura disponible sobre la gestión de las HCE y se evaluó el mecanismo que emplean sistemas homólogos nacionales e internacionales. Para guiar el desarrollo de la propuesta se empleó la metodología AUP-UCI; UML se empleó para el modelado de los artefactos de ingeniería y BPMN como lenguaje de notación para los procesos de negocio. Las modificaciones que se presentan, le permitirán al sistema XAVIA HIS interactuar con sistemas externos que generen documentos HL7-CDA. Adicionalmente, se añaden funcionalidades para mejorar la impresión de documentos clínicos que se exportan, así como la generación de resúmenes de la historia clínica(AU)
One of the e-Health approaches is the digitalization of the medical record, an essential document in health care and with a legal character. The XAVIA HIS system, made up of modules to manage the processes and interconnect the different areas of a hospital institution, has as a fundamental attribute, a unique electronic medical record per patient. It is made up of documents based on the HL7-CDA standard. However, the XAVIA HIS system presents some limitations to interaction with other applications also managing health information. This paper presents the new features and changes to be made to the Hospital Information System XAVIA HIS to improve the electronic medical records management of the mentioned system. An analysis of the available literature on EHR management was carried out and the mechanism used by national and international counterpart systems was evaluated. To guide the development of the proposal, the AUP-UCI methodology was used; UML was used for modeling the engineering artifacts and BPMN as a notation language for business processes. The modifications that are presented will allow the XAVIA HIS system to interact with external systems which also generate HL7-CDA documents. Additionally, functionalities are added to improve the printing of clinical documents that are exported, as well as the generation of summaries of the medical record(AU)
Subject(s)
Humans , Software , Telemedicine/trends , Electronic Health Records , Health Level Seven/standardsABSTRACT
El Sistema de Información Hospitalaria XAVIA HIS desarrollado por el Centro de Informática Médica (CESIM) está compuesto por módulos que aseguran la informatización de los procesos de las áreas de la institución hospitalaria. En la actualidad la gestión de los principales medios de diagnóstico se realiza de forma dispersa en diferentes módulos o sistemas. En este trabajo se presenta el módulo de Medios de Diagnóstico, desarrollo que permite la gestión de informes de solicitudes y resultados de forma configurable, así como la planificación de horarios y gestión de citas. Se analizó el proceso de negocio asociado a la gestión de información de medios de diagnóstico, se realizó un estudio de sistemas existentes con propósitos similares y se evaluaron tecnologías para su implementación. Se utilizó AUP-UCI como metodología de desarrollo, Java como lenguaje de programación y otras tecnologías libres y multiplataforma. El patrón arquitectónico implementado fue modelo-vista-controlador. El módulo de Medios de Diagnóstico del sistema XAVIA HIS, permite el soporte de los procesos de atención al paciente y la integración de la información sobre los medios de diagnóstico, además fomenta un aumento en la calidad del servicio. El módulo facilita la configuración de aspectos de solicitud e informe de las pruebas diagnósticas y la planificación de horarios y citas(AU)
Hospital Information System XAVIA HIS developed by the Medical Informatics Center (CESIM) is made up of modules that ensure the computerization of hospital institution areas processes. Currently, the management of the main diagnostic means is realized in a dispersed way in different modules or systems. This paper presents the Diagnostic Means module, development that allows the requests and results reports management in a configurable way, as well as the schedules planning and appointments management. The business process associated with the diagnostic means information management was analyzed, an existing systems study with similar purposes was carried out, and technologies for their implementation were evaluated. AUP-UCI were used as development methodology, Java as programming language and other free and multiplatform technologies. The architectural pattern implemented was model-view-controller. The XAVIA HIS system Diagnostic Means module, allows the patient care processes support and integration of information regarding diagnostic means, also encourages an increase in the service quality. The module facilitates the request and report aspects configuration of the diagnostic tests and the schedules and appointments planning(AU)
Subject(s)
Humans , Male , Female , Hospital Information Systems/standards , Telemedicine , Diagnostic Techniques and Procedures , Electronic Health Records , Health Level Seven/standardsABSTRACT
Patient diagnosis and treatment data are scattered in various clinical systems related to electronic medical records(EMR). The data can be better applied to the emergency prevention and control, medical research and government supervision only through unified integration. The authors analyzed the construction level of the EMR system in medical institutions, and sorted out the problems faced by directly extracting the diagnosis and treatment data of patients through the EMR system, including the lack of patient-centered integration of data, insufficient application depth of the EMR system, insufficient data standardization, lack of data and so on. Public health emergencies posed a severe challenge to the extraction of EMR data.For medical institutions with different information construction levels, the authors gave a feasibility analysis of data extraction by classification and time period, and suggested that medical institutions should fundamentally strengthen the understanding of information, establish data standard system and realize data integration and unified management.
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Based on a research on judicial cases concerning the authenticity of electronic medical records in the past three years, the authors encountered judicial dilemmas in judicial practice. The challenges arise due to the special manifestations of electronic medical records, unclear and disputable criteria for the authenticity of electronic medical records, low application level of electronic medical records identification, and inconsistent responsibility attribution. In order to effectively apply the electronic medical record system, it is recommend to promote pre-litigation prevention by unifying the construction standards of the computerized patient record system, strengthening hospital electronic medical record management and entrusting third-party storage to ensure the evidential weight. In addition, it is necessary to establish standards for authenticity of medical records, improve the electronic medical record forensic identification system and clarify the attribution of the responsibility for untrue medical records, so as to improve the handling of such medical damage cases during litigation.
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Resumen El objetivo de esta investigación es la modelación del dominio de un marco técnico de compartición e interacción de un expediente clínico electrónico (ECE) entre diversas instituciones de salud, públicas o privadas, como primer paso para lograr un marco técnico de refererencia para la interoperabilidad de sistemas de ECE en México. Se ha utilizado el proceso sistemático KMOS-RE para obterner los diversos artefactos que conforman el modelo: el léxico extendido del conocimiento del domino, los modelos conceptuales del dominio de aplicación y del dominio de la solución y los modelos de estados. Debido a que el diseño e implementación de los sistemas de ECE de cada una de las instituciones de salud se generan de manera independiente, realizar un marco técnico de referencia representa un gran desafío y una gran oportunidad, ya que ofrecerá ventajas importantes, como el hecho de contar con la información clínica de manera oportuna en cualquier institución de salud, la posibilidad de que el propio paciente acceda a su información y la facilidad de realizar investigación clínica a partir de los datos compartidos. Aún cuando la modelación de un dominio es dinámica, el contar con un modelo del dominio lo más preciso posible en este punto, facilitará los siguientes pasos para lograr el marco técnico de referencia propuesto.
Abstract This paper presents the domain modeling of a technical framework of sharing and interaction of an electronic medical record among different healthcare institutions, both public or private, as a first step to establish a technical reference framework for the interoperability of electronic medical record systems in Mexico. The artefact that make up the domain model were carried out using the KMOS-RE systematic process. Through this process, the following components have been obtained: the knowledge domain extended lexicon, the conceptual models, one for the application domain and another for the solution domain, as well as the state models. Since the design and implementation of the electronic medical record systems of different healthcare institutions are generated independently, having a technical reference framework represents a great challenge but also a great opportunity, since it will offer important advantages, such as having the clinical information in a timely manner in any healthcare institution, the possibility of the patient accessing their own information and the ease of conducting clinical research from the shared data. Even when a domain modeling is a dynamic task, having a precise domain model at this point will facilitate the next steps to achieve the proposed technical reference framework.
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Introducción. El subdiagnóstico y subregistro de sobrepeso y obesidad en pediatría es muy frecuente. El uso de una historia clínica electrónica podría contribuir favorablemente. El objetivo fue conocer el porcentaje de registro de este problema por pediatras de cabecera y analizar si se asociaba con la realización de estudios complementarios.Métodos. Estudio de corte transversal. Se evaluó el registro del problema en pacientes pediátricos con sobrepeso y obesidad, y la presencia de resultados de glucemia, triglicéridos y colesterol de alta densidad en pacientes obesos.Resultados. Se analizaron 7471 pacientes con sobrepeso y obesidad; el registro adecuado del problema fue del 19 %. El 44 % de los obesos (n = 1957) tenía registro adecuado y el 32 %, resultados de laboratorio, con asociación significativa entre variables.Conclusiones. Los porcentajes de registro de sobrepeso y obesidad y realización de estudios complementarios fueron bajos. El registro del problema se asoció a mayor solicitud de estudios
Introduction. Under-diagnosis and under-recording of overweight and obesity in pediatrics is very common. Using an electronic medical record may be helpful. The objective was to establish the percentage of recording of this problem by primary care pediatricians and analyze if it was associated with the performance of ancillary tests.Methods. Cross-sectional study. The recording of this problem among overweight and obese pediatric patients and the presence of blood glucose, triglycerides, and high-density lipoprotein cholesterol results in obese patients were assessed.Results. A total of 7471 overweight and obese patients were included; this health problem was adequately recorded in only 19 %. Among all obese patients (n = 1957), 44 % had adequate recording of this health problem; 32 % had lab test results showing a significant association among outcome measures.Conclusions. The percentage of overweight and obesity recording and ancillary test performance was low. Recording was associated with a higher level of test ordering
Subject(s)
Humans , Male , Female , Child, Preschool , Child , Adolescent , Medical Records Systems, Computerized/statistics & numerical data , Overweight/epidemiology , Electronic Health Records , Obesity/epidemiology , Triglycerides , Blood Glucose , Cross-Sectional Studies , Cholesterol, HDLABSTRACT
Resumo Analisaram-se os registros eletrônicos da atenção primária em saúde na cidade do Rio de Janeiro para duas doenças crônicas: hipertensão e diabetes, em um estudo de base populacional, com desenho epidemiológico transversal que considerou a população carioca que possuía "Equipes de Saúde da Família". O cálculo da taxa de prevalência foi estratificado por sexo e faixa etária, e a condição da doença foi mensurada pelos médicos de família nas consultas realizadas por estes, computando-se a CID-10. Excetuando-se as duas últimas faixas etárias (75 a 79 anos e 80 anos e mais), em que parece haver subregistro dos casos diagnosticados, observou-se uma associação positiva entre as taxas de prevalência e a faixa etária, em ambos os sexos. A geração de informações estatísticas objetivas e com confiabilidade é fundamental para a gestão no nível local, permitindo avaliar a dinâmica demográfica e as particularidades de cada território, e auxiliando no planejamento e monitoramento da qualidade dos registros dos cariocas cadastrados em cada unidade de saúde da família. Para isso, a gestão regular de registros duplicados nas listas de usuários cadastrados é fundamental para minimizar o sobreregistro de casos clínicos apontados nos prontuários eletrônicos.
Abstract Primary health care electronic medical records were analyzedin Rio de Janeiro for two chronic diseases, namely, hypertension and diabetes, in a population-based study with a cross-sectional epidemiological design that considered the Rio de Janeiro population enrolled in Family Health Teams. Calculation of the prevalence rate was stratified by gender and age group, and the condition of the disease was measured by family doctors in their visits using the ICD-10.Except for the last two age groups (75-79 years and 80 years and over), with apparent under-registration of the diagnosed cases, a positive association was found between prevalence rates and age in both genders. The generation of objective and reliable statistical information is fundamental for local management, allowing the evaluation of demographic dynamics and the peculiarities of each territory, and assisting in the planning and monitoring of the quality of Rio de Janeiro people's records registered in each family health unit. Thus, the regular management of duplicate records in the registered user roster is essential to minimize the over-registration of clinical cases reported in the electronic medical records.
Subject(s)
Humans , Male , Female , Adult , Aged , Aged, 80 and over , Young Adult , Primary Health Care , Diabetes Mellitus/epidemiology , Electronic Health Records , Hypertension/epidemiology , Brazil/epidemiology , Epidemiologic Studies , Prevalence , Cross-Sectional Studies , Sex Distribution , Age Distribution , Forms and Records Control/methods , Middle AgedABSTRACT
Background: Evaluate the consistency of information in paper-based records when registered in parallel with an electronic medical record.Methods: The study was performed at PMSHC in Dakar Senegal. From the end of year 2016, patients’ files were recorded on both paper-based and electronically. Additionally, previous records were electronically registered. To investigate the completeness of records before and after the electronic recording system has been implemented, information about some maternal and fetal/neonatal characteristics were assessed. When the variable was recorded, the system returned 1, unrecorded variables were coded as 0. We then calculated, for each variable, the unrecorded rate before 2017 and after that date. The study period extended from 2011 to June 2019, a nearly ten-year period. Data were extracted from E-perinatal to MS excel 2019 then SPSS 25 software. Frequencies of unrecorded variables were compared with chi-squared test at a level of significance of 5%.Results: A total of 48,270 unique patients’ records were identified during the eight-year period. Among the study population, data for patients’ age, address and parity were available most of the time before and after 2017 (0.5% missing data versus 0.3% for age and 2.6% versus 1.3% for home address and from 0.3% to 0.0% for parity). However, phone number, maternal weight, maternal height, last menstrual period and blood group were found to be missing up to 96% before 2017. From 2017, these rates experienced a sudden decrease at a significant level: from 82.4% to 27.8% for phone number, from 96% to 56.3% for maternal weight and from 60.1% to 21.3% for blood group. Regarding newborns’ data, it was found that fetal height, head circumference and chest circumference were missing up to just under 25% before 2017. After that date, their completeness improved and flattened under 5%.Conclusions: Structured and computerized files reduce missing data. There is an urgent need the Ministry of health provides hospitals and health care providers with guidelines that describes the standardized information that should be gathered and shared in health and care records.
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Resumen: La implementación de la historia clínica electrónica (HCE) en las organizaciones de salud constituye un proceso de cambio tecnológico. La sustitución del papel por el registro clínico electrónico (RCE) implica que la historia clínica deja de ser un registro de información con un fuerte componente de propiedad por parte del médico y de la organización, e incorpora la integración de la información, el trabajo en equipo, la multidisciplinariedad, las reglas y normas no propias, el acceso ampliamente distribuido al servicio de diversos fines legales y legítimos. El objetivo de esta investigación es identificar los factores de resistencia por parte de los médicos para el uso de la HCE en una institución de atención a la salud. Se realizó una investigación cualitativa a través de entrevistas semiestructuradas y se selecciona la muestra con criterio intencional. En el análisis global de las entrevistas se observa la combinación de diferentes factores de resistencia en cada uno de los profesionales, siendo los más reconocidos: la interferencia en la relación médico-paciente, la mayor demanda de tiempo en el inicio, el temor a lo desconocido, la inadecuación del sistema de trabajo, los intereses de los profesionales médicos. Se identifican, asimismo, distintos tipos de usuarios de tecnología: algunos se han apropiado de la misma, otros son usuarios obligados y otros optan por el no uso. Conclusión, algunas de las barreras pueden ser modificadas directamente desde la gestión del proyecto, por ejemplo, la usabilidad del software, o en las consideraciones del factor tiempo. Sin embargo, hay otras que implican cambios vinculados al comportamiento de los profesionales médicos, que suelen estar relacionados con sus valores y sus creencias, razón que hace más compleja la intervención para el cambio.
Summary: Implementation of electronic medical records (EMRs) in the health system constitutes a process of technological change. Substituting paper for electronic medical records implies the medical record is no longer the registration of information with a great sense of ownership by thy the physician and the institution, and it also brings in the integration of information, team work, multidisciplinariety , rules and norms that are not your own, widely distributed Access to it for different legal and legitimate purposes. This study aims to identify the factors that may result in doctors being against the use of EMRs in a health care institution. We conducted a qualitative research by means of semi-structured interviews and intentionally defined a sample. The global anslysis of the interviews reveals the combination of different factors for resistance in each one of the professionals, the most well known being: interferences in the doctor-patient relationship, the greater demand of time at the start, fear of the unknown, inadequacy of the work system and interests of the health professionals. Likewise, different kinds of technology users are identified: some have embraced it, others are obliged users and other choose not to use it. In conclusion, some of the barriers may be directly modified from the project management, as for instance, the possibility of using the software available, or the impact of time. However, there are other barriers that imply changes in the behaviour of medical professionals that are usually connected to their values and beliefs, what makes interventions seeking change more complex.
Resumo: A implementação do Prontuário Electrónico do Paciente (PEP) nas organizações de saúde constituem um processo de mudança tecnológica. A substituição do papel pelo registro clínico electrónico (RCE) implica que o prontuário do paciente deixe de ser um registro de informação com um forte componente de propriedade por parte do médico e da organização, e incorpora a integração da informação, o trabalho em equipe, a multidisciplinariedade, as regras e normas não próprias, o acesso amplamente distribuído no serviço com diversos fins legais e legítimos. O objetivo deste trabalho foi identificar os fatores de resistência dos médicos no uso do PEP em uma instituição de saúde. Realizou-se um estudo qualitativo com entrevistas semiestruturadas com seleção de amostra com critério intencional. Na análise global das entrevistas observou-se a combinação de diferentes fatores de resistência em cada um dos profissionais, sendo os mais reconhecidos: a interferência na relação médico - paciente, uma demanda maior de tempo no início do processo, o temor ao desconhecido, falta de adequação do sistema de trabalho, e interesses dos médicos. Foram identificados também distintos tipos de usuários de tecnologia: alguns a utilizam como própria, outros são usuários obrigados e outros optam por não usar. Conclusão, algumas das barreiras podem ser modificadas diretamente na gestão do projeto como por exemplo, a usabilidade do software, ou nas considerações relacionadas ao fator tempo. No entanto, existem outras que implicam modificações vinculadas ao comportamento dos médicos, que em geral estão relacionados com seus valores e suas crenças, o que faz com que a intervenção para a mudança seja mais complexa.
Subject(s)
Electronic Health Records , Health Knowledge, Attitudes, PracticeABSTRACT
BACKGROUND: Recently, the number of nationwide medical researches on psoriasis using the National Health Insurance Service database has been on the rise. However, identification of psoriasis using diagnostic codes alone can lead to misclassification. Accuracy of the diagnostic codes and their concordance with medical records should be validated first to identify psoriasis patients correctly.OBJECTIVE: To validate the diagnostic codes of psoriasis (International Classification of Diseases, 10th Revision L40) and to find the algorithm for the identification of psoriasis.METHODS: We collected medical records of patients who received their first diagnostic codes of psoriasis during 5 years from five hospitals. Fifteen percent of psoriasis patients were randomly selected from each hospital. We performed a validation by reviewing medical records and compared 5 algorithms to identify the best algorithm.RESULTS: Total of 538 cases were reviewed and classified as psoriasis (n=368), not psoriasis (n=159), and questionable (n=11). The most accurate algorithm was including patients with ≥1 visits with psoriasis as primary diagnostic codes and prescription of vitamin D derivatives. Its positive predictive value was 96.5% (95% confidence interval [CI], 93.9%~98.1%), which was significantly higher than those of the algorithm, including patients with ≥1 visits with psoriasis as primary diagnostic codes or including ≥1 visits with diagnostic codes of psoriasis (primary or additional) (91.0% and 69.8%). Sensitivity was 90.8% (95% CI, 87.2%~93.4%) and specificity was 92.5% (95% CI, 86.9%~95.9%).CONCLUSION: Our study demonstrates a validated algorithm to identify psoriasis, which will be useful for the nationwide population-based study of psoriasis in Korea.
Subject(s)
Classification , Electronic Health Records , Humans , International Classification of Diseases , Korea , Medical Records , National Health Programs , Prescriptions , Psoriasis , Sensitivity and Specificity , Vitamin DABSTRACT
Objective @#To study patient-related information and factors altering their decision making in periodontal treatment and treatment behavior via big data analysis of the electronic medical records and to guide better dental care service and improve periodontal treatment. @*Methods@# A retrospective study was performed in patients with periodontitis who visited the Affiliated Stomatological Hospital of Tongji University from 2014 to 2016. Based on the periodontal sequence treatment procedure, the treatment types were divided into six groups and were analyzed using multivariable regression analysis. Chi-square test was performed according to gender and age.@*Results@#Age, payment method, disease severity, exhibited statistically significant differences regarding their effects on patients’ treatment behavior (P ＜ 0.05). Men were more likely to have severe periodontitis than women (male 41.04%; female 31.85%), and use medical insurance more often as payment method (male 86.14%; female 83.74%) (P ＜ 0.05). Compared with the population under 35 years old, moderate and severe periodontitis accounted for a larger proportion (84.58%) in the population over 35 years old. The compliance of the population over 35 years old was poor. Less follow-up reviews were conducted (17.10%) and medical insurance was less often used (49.65%) in this population. The differences were statistically significant (P ＜ 0.05).@*Conclusion@#Moderate and severe periodontitis accounted for a larger proportion in the population over 35 years old. Patients over 35 years old tend to choose simpler treatments with lower compliance and frequency of revisits. This situation may be related to the lower proportion of medicare use in this population. The awareness and compliance of periodontal treatment protocols in people over 35 years old needs to be improved.
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Delirium is a common complication in elderly inpatients which could result in cognitive impairment, and increase the risk of disability, fall and mortality. Moreover, it could cause heavy social burden. Even with multiple bedside screening scales to detect delirium, the rate of missed diagnosis is still high. Maybe it is associated with the acute fluctuation and nocturnal onset of delirium. With the development of the intelligence and automation of the electronic medical record (EMR), previous studies have explored the use of EMR to identify delirium patients, and this method provides help for delirium diagnosis and prevention. In this paper, we reviewed and summarized the current situation of research on delirium recognition by EMR, and put forward the development prospect in this method in order to provide basis and lay a foundation for intelligent diagnosis of delirium.
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BACKGROUND: Human leukocyte antigen (HLA) typing is important for transplant patients to prevent a severe mismatch reaction, and the result can also support the diagnosis of various disease or prediction of drug side effects. However, such secondary applications of HLA typing results are limited because they are typically provided in free-text format or PDFs on electronic medical records. We here propose a method to convert HLA genotype information stored in an unstructured format into a reusable structured format by extracting serotype/allele information.METHODS: We queried HLA typing reports from the clinical data warehouse of Seoul National University Hospital (SUPPREME) from 2000 to 2018 as a rule-development data set (64,024 reports) and from the most recent year (6,181 reports) as a test set. We used a rule-based natural language approach using a Python regex function to extract the 1) number of patients in the report, 2) clinical characteristics such as indication of the HLA testing, and 3) precise HLA genotypes. The performance of the rules and codes was evaluated by comparison between the extracted results from the test set and a validation set generated by manual curation.RESULTS: Among 11,287 reports for development set and 1,107 for the test set describing HLA typing for a single patient, iterative rule generation developed 124 extracting rules and 8 cleaning rules for HLA genotypes. Application of these rules extracted HLA genotypes with 0.892–0.999 precision and 0.795–0.998 recall for the five HLA genes. The precision and recall of the extracting rules for the number of patients in a report were 0.997 and 0.994 and those for the clinical variable extraction were 0.997 and 0.992, respectively. All extracted HLA alleles and serotypes were transformed according to formal HLA nomenclature by the cleaning rules.CONCLUSION: The rule-based HLA genotype extraction method shows reliable accuracy. We believe that there are significant number of patients who takes profit when this under-used genetic information will be return to them.
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Clinical studies can be conducted to gather real world evidence (RWE) not available from randomized controlled trials, providing new information and knowledge. Although the concept of RWE emerged relatively recently, numerous clinical studies are utilizing it. However, many researchers are engaging in trial and error that may not overcome the various biases that occur in electronic medical record (EMR)-based RWE studies. While RWE can reflect the real world, there are still limitations to its acceptance. There are many hurdles in using RWE and solutions must be explored. Results based on RWE may be overestimated and it can be difficult to derive good quality results. This paper discusses data quality management, direct chart review, sample size, study design, and the interpretation of EMR-based RWE. More specifically, this paper shares the experience of the various hurdles that occur when conducting RWE studies and discusses the easy-to-false errors. RWE is still in the developmental stage and numerous aspects of RWE use remain unclear. Nonetheless, despite its many limitations, increasing use of RWE is still anticipated. This will require continued experience and effort in using RWE, as well as upgrading RWE research through the accumulation of information on such experiences and efforts.
Subject(s)
Bias , Cohort Studies , Data Accuracy , Electronic Health Records , Sample SizeABSTRACT
Objective To propose a conditional random field (CRF) model based on the new word segmentation method Re-entity, and to compare with bi-directional long short-term memory neural network (BiLSTM)-CRF and Lattice-long short-term memory neural network (LSTM). Methods After analyzing the existing entity recognition methods, we proposed CRF method based on Re-entity, BiLSTM-CRF and Lattice-LSTM for the China Conference on Knowledge Graph and Semantic Computing in 2018 (CCKS2018) task one: Chinese clinical named entity recognition, and trained character vector sets at different parameter levels based on different corpora. The comparative experiments on model performance were carried out in the different neural network models for each methods. Finally, the comparative study was carried out based on different input lengths such as the sentence level and the text level. Results Re-entity method can improve the performance of CRF model. Lattice-LSTM model based on sentence level achieved a strict F1-measure of 89.75% on this task, which was higher than the highest F1-measure (89.25%) on the task one of CCKS2018. Conclusion The CRF model based on Re-entity can effectively improve the recognition rate of traditional Chinese medicines in electronic medical records by using normalized Chinese clinical drug. Re-entity method can improve the error accumulation caused by word segmentation in data preprocessing. Lattice structure can better combine the latent semantic information of characters and word sequences. At the same time, sentence-level input can effectively improve the recognition accuracy of neural network models.
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Objective:To design a method of similarity duplicate checking for structured electronic medical record so as to solve the problem of quality control of illegal copy in structured electronic medical records.Methods:To define the duplicate checking property of document template and document segment of structured electronic medical record, and adopt knuth-morris-pratt (KMP) of minimum ratio of similitude to achieve duplicate checking for similar medical record and look up medical records that were copy by using deregulation method.Results:It can find medical records with similar ratio greater than a fixed threshold from structured electronic medical records, and check the similarity of illegally copied medical records.A total of 173 copies of illegally copied medical records were found from more than3500 medical records.Conclusion:The similarity duplicate checking method of structured electronic medical records can realize look up medical record that is copied by using deregulation from structured electronic medical record files, and can effectively control quality of medical records of hospital.
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Objective To explore the effective strategies of clinical pathway construction in intensive care unit (ICU).Methods From January 2016 to July 2018,1 488 patients were discharged from ICU of Liuzhou Worker's Hospital of Guangxi Zhuang Autonomous Region.The pilot project of "postoperative monitoring of heart disease" with simpler route and less variation was selected first,and then the pilot project was promoted to "post-operative monitoring" after its success.The implementation of the clinical pathway was divided into three stages:the first stage,January 2016 to May 2017,for the pilot phase,a total of 87 patients were enrolled in the clinical pathway trial;the second stage,June 2017 to December 2017,surgical ICU "postoperative monitoring of heart disease" was put into the pathway 111 times;the third stage,January 2018 to July 2018,surgical ICU "postoperative monitoring of heart disease" was entered in the path 116 times;comprehensive ICU "postoperative care" was put into the path 96 times.After carefully analyzed the reasons and sum up the experience,internet+medical treatment (Liuzhou Worker's Hospital became the fifih deep partner of Tencent Inc in the internct+medical field,and carried out the plan and practice of "WeChat wisdom hospital 3.0" in 2017) was used,four aspects of connection,payment,security and ecological cooperation were upgraded,and the construction of 6 level of electronic medical record (EMR) was accelerated.At the same time,through diagnosis related groups system (DRGs),the concept of evidence-based medicine,quality management and continuous improvement as the leading factor,and combined with the construction status of hospital information system (HIS) and EMR system,step by step implementation and design of information management platform for clinical pathway were formulated.The completion rate of clinical pathway,average length of hospital stay,average cost,cure rate and improvement rate were the main observation parameters.Results In the first stage,none of the 87 patients who entered the clinical pathway completed the clinical pathway.In the second stage,the completion rate of surgical ICU clinical pathway was increased from 33.33％ in June 2017 to 94.44％ in December 2017,and up to 100％ in October 2017,and the average completion rate from January to July 2018 was 94.00％.The completion rate of ICU clinical pathway was increased from 81.82％ in January 2008 to 92.86％ in July 2008.There was a significant difference in the overall clinical pathway completion rate from 2016 to 2018 (x2 =204.300,P =0.000).After the effective implementation of clinical pathway in June 2017,the length of hospital stay of patients was significantly shortened as compared with that before implementation (days:2.96 ± 0.43 vs.6.66 ± 0.75,P ＜ 0.01),and the daily cost was significantly reduced (Yuan:3 550.92 ± 755.51 vs.6 171.48 ± 377.29,P ＜ 0.01).The average length of hospital stay was shortened by about 3.84 days (P ＜ 0.01),and the average daily cost was reduced by about 2 108.39 Yuan (P ＜ 0.01) after the implementation of clinical pathway by surgical ICU "postoperative monitoring of heart disease" as compared with those before implementation.The average length of hospital stay was shortened by about 2.98 days (P ＜ 0.01) and the average daily cost was reduced by 5 094.13 Yuan (P ＜ 0.01) after the implementation of clinical pathway by comprehensive ICU "post-operative monitoring" as compared with those before implementation.At the same time,the cure rate was increased from 1.16％ (7/603) to 42.26％ (105/227),and the improvement rate was decreased from 94.36％ (569/603) to 52.86％ (120/227,both P ＜ 0.01) after the implementation of surgical ICU clinical pathway,but there was no significant difference in the cure rate or the improvement rate after the implementation of comprehensive ICU [2.77％ (33/1 193) vs.2.22％ (2/90),79.21％ (945/1 193) vs.97.78％ (88/90),both P ＞ 0.05].Conclusions Application of clinical pathway to control ICU quality and guide diagnosis and treatment,more refined diagnosis and treatment schemes including clinical guidelines,average length of stay,average cost of hospitalization,cost-efficiency ratio and so on were completed,which confirmed that the improvement of clinical pathway management strategy originated from clinical were needed.Informatization,intellectualization,standardization and effective control of medical cost of clinical pathway could improve medical quality and accurate management.The integration of ICU clinical pathway construction and HIS could promote the development of digital hospitals.