O que dizem as informações sobre mortalidade dos Registros Hospitalares de Câncer (RHC) em hospital de referência de Minas Gerais, 2016-2017 / What the information on mortality from the Hospital Cancer Registry (RHC) reveals about a reference hospital in Minas Gerais, 2016-2017

Resumo Introdução A qualidade das informações dos Registros Hospitalares de Câncer (RHC) necessita de avaliação quanto à cobertura, completitude e concordância da causa básica(CB) com o Sistema de Informações sobre Mortalidade (SIM). Objetivo Avaliar a qualidade dos RHC nas duas unidades hospitalares do Instituto Mário Penna: Hospitais Mário Penna (HMP) e Luxemburgo (HL), Belo Horizonte, Minas Gerais, em 2016 e 2017, nos atributos mencionados. Método Por captura-recaptura (RHC x RHC), avaliaram-se, por unidade, cobertura, completitude da variável "óbito por câncer" e concordância da a (CB) com a causa da pesquisa (CP). Por relacionamento determinístico (RHC x SIM) avaliaram-se cobertura e concordância da CB. Resultados A cobertura dos RHC foi boa eexcelente (88,8% e 95,3%); a completitude foi ruim (34,6% e 32,6%) no HMP e HL respectivamente; por capítulo da CID-10, não houve concordância da CB com a CP. Observaram-se excelentes cobertura (94,7%) e concordância (94,5%) entre CP e SIM; observou-se sub-registro de 38 neoplasias no SIM, com reclassificação de causas pouco úteis. Conclusão A aplicação das técnicas de captura-recaptura e relacionamento determinístico contribuiu para a melhora da qualidade da informação dos RHC, com redução da incompletude nos RHC e correção da CB nos RHC e no SIM.

Abstract Bakground The quality of information from the Hospital Cancer Records (HRC) needs to be evaluated regarding coverage, completeness and agreement between the underlying cause (UC) as registered in the HRC and the Mortality Information System (SIM). Objective To assess the quality of the HRC in the two Instituto Mário Penna hospitals: Mário Penna (HMP) and Luxemburgo (HL) in Belo Horizonte, Minas Gerais, between 2016-2017. Method By capture-recapture (RHC x RHC), we assessed coverage, completeness of the "cancer death" variable and agreement between underlying cause (UC) with the cause of the research (CR), in each hospital. Deterministic relationship (RHC x SIM) was used to asses UC coverage and agreement between systems. Results The coverage of deaths at the HRC was good/excellent (88.8% and 95.3%); completeness was poor (34.6% and 32.6%) in HMP and HL respectively; per ICD-10 chapter, there was no agreement between CB and CP. Excellent coverage (94.7%) and agreement (94.5%) of CR and SIM were observed; 38 neoplasms were under-reported in the SIM, with reclassification of less useful causes. Conclusion Applying capture-recapture and deterministic linkage techniques contributed in improving the quality of information in the HRC, with a reduction in incompleteness in the HRC and correction of the UC in both HRC and SIM.

Clinical Decision Support Functions and Digitalization of Clinical Documents of Electronic Medical Record Systems / 대한의료정보학회지

OBJECTIVES: The objective of this study was to investigate the clinical decision support (CDS) functions and digitalization of clinical documents of Electronic Medical Record (EMR) systems in Korea. This exploratory study was conducted focusing on current status of EMR systems. METHODS: This study used a nationwide survey on EMR systems conducted from July 25, 2018 to September 30, 2018 in Korea. The unit of analysis was hospitals. Respondents of the survey were mainly medical recorders or staff members in departments of health insurance claims or information technology. This study analyzed data acquired from 132 hospitals that participated in the survey. RESULTS: This study found that approximately 80% of clinical documents were digitalized in both general and small hospitals. The percentages of general and small hospitals with 100% paperless medical charts were 33.7% and 38.2%, respectively. The EMR systems of general hospitals are more likely to have CDS functions of warnings regarding drug dosage, reminders of clinical schedules, and clinical guidelines compared to those of small hospitals; this difference was statistically significant. For the lists of digitalized clinical documents, almost 93% of EMR systems in general hospitals have the inpatient progress note, operation records, and discharge summary notes digitalized. CONCLUSIONS: EMRs are becoming increasingly important. This study found that the functions and digital documentation of EMR systems still have a large gap, which should be improved and made more sophisticated. We hope that the results of this study will contribute to the development of more sophisticated EMR systems.

Prontuário eletrônico do paciente: Avaliação de usabilidade pela equipe de Enfermagem / Eletronic health records: Evaluation of usability by the nursing team / Prontuario electrónico del paciente: evaluación de usabilidad por el equipo de enfermería

This work aimed to evaluate the usability and the difficulties met by 99 nursing professionals using electronic health records. It is exploratory quantitative research, based on data collected in July ­ November 2013. The results show that 71% of the auxiliary nurses/nursing technicians and 70% of the nurses had not received specific training; 56% of the team, who stated that they had not received training experienced difficulty in using the system. Among the characteristics of usability of the electronic health record evaluated, suitability to the task stood out positively, while suitability to learning stood out negatively. The system evaluated, therefore, in spite of the advances arising from it, is still presented as complex to the user who has not received training, in spite of its having a consistent and interactive interface (AU).

O objetivo deste trabalho foi avaliar a usabilidade e as dificuldades encontradas por 99 profissionais de enfermagem no manuseio de prontuário eletrônico do paciente. Pesquisa exploratória quantitativa a partir da coleta de dados no período de julho a novembro de 2013. Os resultados demostram que 71% dos auxiliares/técnicos e 70% dos enfermeiros não receberam treinamento específico; sendo que 56% da equipe, que respondeu não ter Received treinamento, apresenta dificuldade no uso. Dentre as características avaliadas de usabilidade do prontuário eletrônico do paciente destacam-se positivamente a adequação à tarefa e negativamente à adequação ao aprendizado. Portanto, o sistema avaliado, apesar dos avanços advindos, ainda se apresenta complexo para o usuário que não recebeu treinamento, apesar de possuir interface consistente e interativa (AU).

El objetivo de este trabajo fue evaluar la usabilidad y las dificultades halladas por 99 profesionales de enfermería en el manoseo de prontuario electrónico del paciente. Investigación exploratoria cuantitativa hecha por medio de la obtención de datos en el periodo de julio a noviembre de 2013. Los resultados apuntan que 71% de los auxiliares/técnicos y 70% de los enfermeros no tuvieron entrenamiento específico; siendo que 56% del equipo, que contestó no tener entrenamiento, presenta dificultad en el uso. Entre las características evaluadas de usabilidad del prontuario electrónico del paciente se destacan positivamente la adecuación a la tarea y, negativamente, la adecuación al aprendizaje. Por lo tanto, el sistema evaluado, a pesar de los avances, todavía se presenta complejo para el usuario que no tuvo entrenamiento, a pesar de poseir interfaz consistente e interactiva (AU).

Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System / 대한의료정보학회지

OBJECTIVES: The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. METHODS: This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. RESULTS: We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. CONCLUSIONS: The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.

Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System / 대한의료정보학회지

OBJECTIVES: The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. METHODS: This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. RESULTS: We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. CONCLUSIONS: The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.

Applicability of the ISO Reference Terminology Model for Nursing to the Detailed Clinical Models of Perinatal Care Nursing Assessments / 대한의료정보학회지

OBJECTIVES: The purpose of this study was to examine the applicability of the International Organization for Standardization (ISO) reference terminology model for nursing to describe the terminological value domain content regarding the entities and attributes of the detailed clinical models (DCMs) used for nursing assessments. METHODS: The first author mapped 52 DCM entities and 45 DCM attributes used for perinatal care nursing assessments to semantic domains and their qualifiers to the ISO model. The mapping results of the entity and attribute concepts were classified into four categories: mapped to a semantic domain qualifier, mapped to a semantic domain, mapped to a broader semantic domain concept, and not mapped. The DCM mapping results were classified into three categories: fully mapped, partially mapped, and not mapped. The second author verified the mapping. RESULTS: All of the entities and 53.3% of the attribute concepts of the DCMs were mapped to semantic domains or semantic domain qualifiers of the ISO model, 37.8% of the attributes were mapped to the broader semantic domain concept, and 8.9% of the attributes were not mapped. At the model level, 48.1% of the DCMs were fully mapped to semantic domains or semantic domain qualifiers of the ISO model, and 51.9% of the DCMs were partially mapped. CONCLUSIONS: The findings of this study demonstrate that the ISO reference terminology model for nursing is applicable in representing the DCM structure for perinatal care nursing assessment. However, more qualifiers of the Judgment semantic domain are required in order to clearly and fully represent all of the entities and attributes of the DCMs used for nursing assessment.

The development and application of active RFID entrance management system for emergency patient safety / 대한의료정보학회지

OBJECTIVE: Unauthorized exit of emergency patients could cause serious safety problems in the emergency room. If the entry and exit of emergency patients can be monitored by RFID (Radio Frequency Identification) technology, such safety issues may be resolved. METHOD: We determined the fundamental requirements of the system for emergency patient safety, and chose an active RFID tag to conduct the recognition test. Subsequently, we performed the entrance recognition rate test and safety test using pacemakers. After developing the entrance management programs, we implemented the system in the emergency room and collected data for 6 months. RESULT: The overall success rate of the entrance recognition test was 99.5%, and during the safety test, pacemaker oversensing due to noise did not occur. We intended to fulfill the fundamental requirements in developing entrance management programs. A total of 508 patients were given RFID tags for the study period, and the recognition failure rate was 4.7%. "Alert" pop-ups occurred 62 times. CONCLUSION: An active RFID entrance management system would be very useful for safety management in emergency room because the system enables detection of the unauthorized exit of emergency patients in real. time.

The Business Analysis on the Chronic Disease Management in PublicHealth Centers for the Electronic Health Records System / 대한의료정보학회지

OBJECTIVE: This study analyzes the chronic disease management, which is a core business of the public health centers, and grasps the functions of the information system that users need. METHODS: It is conducted by analyzing work flows in two public health centers that using two different health information systems, Posdata system and Daeryun systems. We also performed detailed interview and discussion to formulate the functionality for the information system in the future. RESULTS: Both two health information systems currently used at public health centers emphasized hypertension, diabetes mellitus and hyperlipidemia as major target disease. They used information systems as a tool of case registration, assessment, reporting, consultation and education and patient care. But functionality of current systems supports only a part of the whole system and manual data input using excel program was still applied. The current information system is just inputting the data of manual works in computer and many of the functions are not used and still there are many duplicate and manual works. Two major problems of information systems in Korean public health centers are lack of standardization in the business process and reporting, and the current system does not support current functionalities. CONCLUSION: We found that management of the chronic disease is to be more important work for the public health centers in the future. The future direction of the work process of the management of chronic disease would be upgrading the current functionality as well as new functionalities. Better linkage with direct care system and interoperability with national electronic health records system are new demands.