Experiencias sobre la implementación del Expediente Clínico Electrónico / Experiences on the implementation of the Electronic Medical Record

Resumen Introducción. Un elemento de la e-salud que ha cobrado gran relevancia es el Expediente Clínico Electrónico (ECE) ya que es un medio para lograr mejores resultados en la práctica médica. Al momento, han sido pocas las investigaciones que se han centrado en analizar e identificar la situación de esta estrategia en el mundo. Por ello, el objetivo de esta investigación es analizar el panorama actual del ECE en diversos países considerando las ventajas, desventajas, desafíos y factores de éxito en su implementación. Metodología: Se realizó una revisión de la literatura existente sobre el ECE en base de datos especializadas. Para obtener estos estudios se utilizó la base de datos de scopus y sciencedirect , utilizando palabras de búsqueda como como registro electrónico de salud, registro médico electrónico o expediente clínico electrónico; se seleccionaron solamente aquellos estudios con un alto factor de impacto, mismo que se refiere al número de veces que se hayan citado los artículos consultados. Se seleccionaron y analizaron 64 estudios académicos. Resultados. Se encontró que aún existen importantes desafíos y desventajas en la implementación del ECE como la interoperabilidad semántica y el estrés laboral que genera en los usuarios este sistema. Conclusiones. Existen cuestiones importantes que aún quedan por resolver para una implementación eficaz del ECE. Es necesario integrar a todos los involucrados en el proceso de cambio, así como establecer las medidas de seguridad necesarias para garantizar la privacidad de la información.

Abstract Introduction. An element of e-health that has gained great relevance is the Electronic Medical Record (ECE) since it is a means to achieve better results in medical practice. At the moment, few investigations have focused on analyzing and identifying the situation of this strategy in the world. Therefore, the objective of this research is to analyze the current panorama of ECE in various countries considering the advantages, disadvantages, challenges and success factors in its implementation. Methodology. A review of the existing literature on ECE was carried out in specialized databases. To obtain these studies, the scopus and sciencedirect databases were used, using search words such as "electronic health record", "electronic medical record" or "electronic medical record"; Only those studies with a high impact factor were selected, which refers to the number of times the articles consulted have been cited. 64 academic studies were selected and analyzed. Results. It was found that there are still important challenges and disadvantages in the implementation of ECE such as semantic interoperability and the work stress that this system generates in users. Conclusions. There are important issues that remain to be resolved in the effective implementation of the ECE. It is necessary to integrate all those involved in the change process as well as to establish the necessary security measures to guarantee the privacy of the information.

Conocimientos, actitudes, prácticas y subregistro de dengue en el municipio de Tocaima, Cundinamarca, 2019 / Knowledge, acttitudes, practices and dengue under registration Tocaima, Cundinamarca 2019

Introducción. Pese a las estrategias de vigilancia se cree que existe subregistro de dengue, lo que puede ser secundario a la no detección de casos ya sea por no consulta del paciente, por falla en el diagnóstico o diligenciamiento de fichas de notificación. Objetivo. Estimar el subregistro de los casos de dengue en el municipio de Tocaima durante el periodo de enero a septiembre de 2019 y establecer los conocimientos, actitudes y prácticas respecto al dengue de los habitantes del municipio. Metodología. Se realizó un estudio transversal de prevalencia durante el período de enero a septiembre de 2019 en la población urbana de Tocaima, mediante encuestas a dos viviendas de las 262 manzanas seleccionadas por muestreo aleatorio simple en la búsqueda activa comunitaria y en el 100% de los registros individuales de prestación de servicios y del sistema de vigilancia nacional en salud pública SIVIGILA mediante Búsqueda Activa Institucional BAI. Resultados. Se encuestaron 440 personas de las cuales 19 manifestaron haber presentado síntomas y signos de dengue en el periodo de estudio, de estos, seis personas no asistieron a consulta médica. El Subregistro Comunitario por falta de asistencia a consulta médica fue de 31,5%. Se identificaron en SIVIGILA 125 casos de dengue notificados en el periodo y 156 en el Registro Individual de Prestación de Servicios (RIPS), aplicando el método de Chandra-Sekar Deming se estimaron un total de 257 casos, para un Subregistro Institucional de SIVIGILA de 48,5%. Conclusiones. Son diversas las razones por las cuales no se notificaron todos los casos de la enfermedad al sistema de vigilancia, la primera es que solo se notifican los casos de las personas que consultan a los servicios de salud y que además viven en Tocaima, la segunda es que algunos casos detectados no se notificaron al sistema de vigilancia por errores de procedimiento, o por desconocimiento del diagnóstico por el personal de salud.

Introduction. Despite the surveillance strategies, it is believed that there is an underreporting of dengue, which may be secondary to the non-detection of cases, either due to non-consultation of the patient, due to failure in the diagnosis or filling in of notification sheets. Objective. Estimate the under-registration of dengue cases in the municipality of Tocaima during the period from January to September 2019 and to establish the knowledge, attitudes and practices regarding dengue of the inhabitants of the municipality. Methodology and materials. A cross-sectional study of prevalence was carried out during the period from January to September 2019, in the urban population of Tocaima, through surveys of 2 dwellings of the 262 blocks selected by simple random sampling in the active community search, and in 100% of individual records of service provision and Sivigila through institutional active search. Results. 440 people were surveyed, 19 of whom reported having symptoms and signs of dengue in the study period, of these, six people did not attend a medical consultation. The Community Under-registration for lack of attendance at medical consultation was 31.5%. 125 cases of dengue reported in the period were identified in SIVIGILA and 156 in the Individual Service Provision Registry (RIPS), applying the Chandra-Sekar Deming method, a total of 257 cases were estimated, for a SIVIGILA Institutional Sub-registry of 48,5%. Conclusions. There are several reasons why not all cases of the disease were notified to the surveillance system, the first is that only the cases of people who consult the health services and who also live in Tocaima, the second, some cases detected were not notified to the surveillance system due to procedural errors, or due to lack of knowledge of the diagnosis by health personne.

Computer-based clinical coding activity analysis for neurosurgical terms / 영남의대학술지

BACKGROUND: It is not possible to measure how much activity is required to understand and code a medical data. We introduce an assessment method in clinical coding, and applied this method to neurosurgical terms.METHODS: Coding activity consists of two stages. At first, the coders need to understand a presented medical term (informational activity). The second coding stage is about a navigating terminology browser to find a code that matches the concept (code-matching activity). Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) was used for the coding system. A new computer application to record the trajectory of the computer mouse and record the usage time was programmed. Using this application, we measured the time that was spent. A senior neurosurgeon who has studied SNOMED CT has analyzed the accuracy of the input coding. This method was tested by five neurosurgical residents (NSRs) and five medical record administrators (MRAs), and 20 neurosurgical terms were used.RESULTS: The mean accuracy of the NSR group was 89.33%, and the mean accuracy of the MRA group was 80% (p=0.024). The mean duration for total coding of the NSR group was 158.47 seconds, and the mean duration for total coding of the MRA group was 271.75 seconds (p=0.003).CONCLUSION: We proposed a method to analyze the clinical coding process. Through this method, it was possible to accurately calculate the time required for the coding. In neurosurgical terms, NSRs had shorter time to complete the coding and higher accuracy than MRAs.

Relato de experiencia: Grupo de monitoreo del plan estratégico de un hospital público en Argentina / An Account of Experience: A Strategic Plan Monitori ng Group at a Public Hospital in Argentina

INTRODUCCIÓN:El presente artículo comparte la experiencia de un trabajo llevado a cabo en relación a la planificación estratégica y su monitoreo en las reuniones del Grupo de Monitoreo del Plan Estratégico del "Hospital El Cruce, Alta complejidad en Red, Néstor Kirchner", de gestión pública, en Argentina. MÉTODOS: Es un estudio descriptivo que registra la dinámica y las actividades que el Grupo llevó a cabo: inicialmente abocadas a la medición y el reporte, para después pasar a convertirse en una herramienta de gestión, planificación estratégica, indicadores, Programas Operativos Anuales, estrechando lazos en ámbitos de salud entre la gestión y lo asistencial. CONCLUSIONES:El conjunto de acciones representa un insumo para generar un cambio organizacional basado en un registro continuo, análisis sistemático para poder concluir en toma de decisiones basadas en las prácticas y hechos reales.

INTRODUCTION:This article shares the experience of the strategic planning work and its monitoring in the meetings of the Strategic Plan Monitoring Group at the publicly managed El Cruce, Néstor Kirchner Hospital in a high-complexity network in Argentina. METHODS: It is a descriptive study that records the dynamics and the activities performed by the Group: initially devoted to measuring and reporting, then it turned into a management and strategic planning tool, with indicators, Annual Operative Programs and strengthening links between management and health care in health settings. CONCLUSIONS: This set of actions represents a resource aimed at generating an organizational change based on an ongoing recording and systematic analysis to finally allow for the decision-making on the basis of practice and real facts.

Proposal for improving the education and licensing examination for medical record administrators in Korea / 보건의료교육평가

No abstract available.

Information needs and information resources availability for nursing students in mission-Owned schools of nursing in Imo state

This study investigated the information needs and information resources availability for nursing students in mission-owned schools of nursing in Imo State. The study adopted the descriptive survey research design and five research questions guided the study. All the 416 second and third year nursing students were used for the study. Questionnaire on Information Needs of Nursing Students and a Checklist on Information Resources Availability were the instruments used to collect data. A total of 397 copies of the questionnaire were completed and returned for analysis representing 95.4% of the total population. All the head- librarian of the schools of nursing complied with the checklist. The findings showed that the students need varieties of information. It also showed that the students consulted different sources, mainly textbooks and internet to meet their information needs. Print information resources were available in the libraries and only few electronic information resources were available. The study recommended that the nursing school authorities should be updating their print resources since students were observed to rely more on textbooks. Also the libraries should upgrade to higher bandwidth so as to have easier and faster access to more e-books and e-journals.Keywords: Information, Information needs, Print and Electronic Information Resources Availability, Nursing Education

Job satisfaction and personal factors among medical librarians: empirical evidence from teaching hospitals in southern Nigeria

This study was to provide empirical evidence of areas of job satisfaction among medical librarians, as well as record difference in job satisfaction based on personal factors (sex, age, educational qualification and years of work experience) of medical librarians in Southern Nigeria. The study used the descriptive survey method and made use of medical librarians from six selected teaching hospitals the Southern part of Nigeria. The study employed the use of a questionnaire adapted from the Minnesota Satisfaction Questionnaire (MSQ) for the collection of data. The data collected were analyzed using Mean, Standard Deviation (SD), student t-test, and Analysis of Variance (ANOVA) at 0.05 level of significance. Five areas of job satisfaction were investigated. Results revealed that medical librarians are not satisfied with two areas, while they expressed satisfaction in three areas. The study recorded no significant difference in the job satisfaction of medical librarians based on their personal factors. Key Words: Job Satisfaction, Personal Factors, Medical Librarians, Teaching Hospitals.

Creating value-based medical library services through competitive intelligence

Competitive Intelligence is a management tool that enables top executives make smart, successful and strategic decisions thereby minimizing risk, avoiding being short-sighted, and getting it right the first time. The paper is a review on how the medical library can employ competitive intelligence to enhance their services in the healthcare organization. The paper notes that competitive intelligence will enable Medical Libraries to offer innovative and creative services. The paper concludes that medical librarians and information professionals should be re-positioned to become strategic part ofthe corporate information environment. They must also become more proactive in promoting their services andprojecting their library within their own organization.

Professional library services in federal neuropsychiatric hospital, YABA Lagos

This paper is a review of professional library services in Federal Neuropsychiatric Hospital, Yaba. The paper noted that the important role of Medical Librarians in facilitate access to the medical literature for health professionals and students. Data from the library statistics show there is increase in patronage from 4040 library visits in 2011 to 6395 in 2015. Students use the library most. Hospital staff and researchers also use the library. Information services performed in library include current awareness services, Strategic dissemination of information. It was recommended that availability and utilization of ICT or e- library in library should be a priority. Adequate funding, infrastructures development and provision of uninterrupted electricity for conducive learning environment were highly recommended.

Evaluación de historias clínicas elaboradas en salas de hospitalización de medicina interna del Hospital Escuela / Evaluation of medical history completed in Internal Medicine Wards in the Hospital Escuela

La historia clínica es bastión en la práctica médica, debe ser elaborada de forma sistemática y evaluarse objetivamente. En el Hospital Escuela no existe un modelo único ni forma de evaluarla, debido a ello se realizó el presente estudio. Objetivo: Evaluar la estructura de la Historia Clínica (HC) elaborada por estudiantes de la Facultad de Ciencias Médicas. Métodos: Se realizó un estudio transversal descriptivo, mediante la revisión de 626 expedientes de pacientes de salas de Medicina Interna en el periodo del 13 de noviembre 2010 al 23 de febrero 2011, con la finalidad de analizar la estructura de las HC; estas se cotejaron con una HC modelo que fue el instrumento de trabajo, la estructura del modelo se basó en libros de textos y en el programa de la asignatura Introducción a la Clínica. El estudio se realizó en 3 etapas: validación del instrumento en 12 expedientes, revalidación o ensayo preliminar en 100 historias de 302 expedientes y fase final: evaluación de 100 historias de 312 expedientes. Resultado: de las 100 historias evaluadas, 55 eran de pacientes mujeres, 31 de hombres y en 14 esta información no se consignó. Los datos generales fueron consignados en las 100 HC; al describir el síntoma principal se utilizó lenguaje técnico, presente en 91 HC, en 99 se encontraba descrita la historia de la enfermedad actual aunque redactada en forma confusa, en 95 no se realizó en forma lógica y solamente en 9 HC se plasmó la evolución en forma coherente y lógica. El uso de parámetros semiológicos se describió en 99 HC dificultando el análisis de las mismas, uno de los parámetros de importancia es el tratamiento recibido por el paciente, se describió en 29 historias y en 42 se consignó los atenuantes y precipitantes. Las funciones orgánicas generales fueron muy bien descritas en 99 HC, agregándose en este apartado la descripción por órganos, aparatos y sistemas. Los antecedentes no patológicos y patológicos se describieron en 85 y 98 respectivamente...

Auditoria de prontuário do paciente: um processo de apredizagem e integração institucional / Audit patient record: a learning process and institucional integration

O presente trabalho analisa medidas institucionais tomadas pelo Hospital Municipal e Maternidade Escola de Vila Nova Cachoeirinha para a melhoria do preenchimento do prontuário do paciente, e relata as ações da Comissão de Revisão de Prontuário, que em parceria com a Assessoria de Qualidade, instituiu desde 2005 a auditoria nos prontuários e, posteriormente, em 2008, implantou o Serviço de Auditoria do Prontuário do Paciente, que realiza auditoria retrospectiva após alta. Em média são auditados entre 450 e 500 prontuários por mês, o que representa média de 50 por cento das internações. Inicialmente, as não conformidades referentes à identificação de alguns profissionais e à identificação do paciente ficaram acima de 10 por cento. Várias medidas foram tomadas para alterar a situação, entre elas a criação do Manual do Prontuário; refinamento da padronização dos formulários; aula obrigatória e curricular para residentes; e aula pocket sobre a utilização dos formulários usados apenas por cada setor. Também foi criado o Check List setorial, que funciona como uma planilha de auditoria mais concisa, utilizado para conferência direta dos formulários de cada setor e funcionando como auditoria concorrente realizada ainda enquanto o paciente está hospitalizado. Concluiu-se que a auditoria é um elemento essencial para mensurar a qualidade assistencial.

Comparison of Knowledge Levels Required for SNOMED CT Coding of Diagnosis and Operation Names in Clinical Records / 대한의료정보학회지

OBJECTIVES: Coding Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT) with complex and polysemy clinical terms may ask coder to have a high level of knowledge of clinical domains, but with simpler clinical terms, coding may require only simpler knowledge. However, there are few studies quantitatively showing the relation between domain knowledge and coding ability. So, we tried to show the relationship between those two areas. METHODS: We extracted diagnosis and operation names from electronic medical records of a university hospital for 500 ophthalmology and 500 neurosurgery patients. The coding process involved one ophthalmologist, one neurosurgeon, and one medical record technician who had no experience of SNOMED coding, without limitation to accessing of data for coding. The coding results and domain knowledge were compared. RESULTS: 705 and 576 diagnoses, and 500 and 629 operation names from ophthalmology and neurosurgery, were enrolled, respectively. The physicians showed higher performance in coding than in MRT for all domains; all specialist physicians showed the highest performance in domains of their own departments. All three coders showed statistically better coding rates in diagnosis than in operation names (p < 0.001). CONCLUSIONS: Performance of SNOMED coding with clinical terms is strongly related to the knowledge level of the domain and the complexity of the clinical terms. Physicians who generate clinical data can be the best potential candidates as excellent coders from the aspect of coding performance.

Needs Assessment for Functionalities in Electronic Health Record Systems in General Hospitals / 대한의료정보학회지

OBJECTIVE: As an electronic health record system is implementing in Korean health care sectors, concerns about key functionalities of electronic health record systems are increasing. The purpose of this study was to identify core functions and set the priority in electronic health record systems under the Korean contexts in order to assure and improve the quality of the systems. METHODS: A survey was conducted using questionnaire developed by the study team based on literature review. The subjects were medical record administrators working at medical record department in general hospitals. RESULTS: The response rate was 59.8%(55/92). The functions which more than ninety percent of subjects responded as necessary right now and/or in near future related to 'drug alert', 'clinical guideline', 'chronic disease management', 'automated real-time surveillance', 'coded data', 'result reporting', 'de-identifying data', 'disease registry', and 'provider-provider communication and connectivity'. CONCLUSION: The results showed the high prioritized functions were decision support and health information/data management.

study of the necessity of librarians and medical informants cooperation in approved research plans from research executers point of view in 2003

The scientific, technical, economic and social development of a society is closely connected to the amount of information produced by its managers, researcher and scholars. In this study, the necessity of the librarians and medical informants' cooperation in the approved research plans of IUMS was investigated. It was a descriptive study in which the participants were 96 research executives who performed research in 2003 under he supervision of Isfahan University of Medical Sciences research deputy. The data were collected by a questionnaire which was checked for its validity and reliability. The findings revealed that 81.3% of the research executives asserted that it was necessary to have access to librarians and medical informants in a research team. Regarding the positive views of research executives, it was suggested that it would be essential to have contact with librarians and medical informants and to consult with a statistical advisor

Normas básicas de administración de la historia clínica / Basic standard of administration of the clinic history

Este capítulo trata sobre las normas básicas de la administración de la historia clínica

The Accuracy of ICD codes for Cerebrovascular Diseases in Medical Insurance Claims / 예방의학회지

OBJECTIVES: We attempted to assess the accuracy of ICD codes for cerebrovascular diseases in medical insurance claims (ICMIC) and to investigate the reasons for error. This study was designed as a preliminary study to establish a nationwide surveillance system. METHODS: A total of 626 patients with medical insurance claims who indicated a diagnosis of cerebrovascular diseases during the period from 1993 to 1997 was selected from the Korea Medical Insurance Corporation cohort (KMIC cohort: 115,600 persons). The KMIC cohort was 10% of those insured who had taken health examinations in 1990 and 1992 consecutively. The registered medical record administrators were trained in the survey technique and gathered data from March to May 1999. The definition of cerebrovascular diseases in this study included cases which met one of two criteria (Minnesota, WHO) or 'definite stroke' in CT/MRI finding. We questioned the medical record administrators to explain the error if the final diagnoses were not coded as stroke. RESULTS: The accuracy rate of the ICMIC was 83.0% (425 cases). Medical records were not available for 8.2% (51 cases) due to the closing of hospitals, the absence of a computer system or omission of medical record, etc. Sixty-three cases (10.0%) were classified as impossible to interpret due to insufficient records in 'major clinical symptoms' or 'neurological deficits'. The most common reason was 'to meet review criteria of medical insurance benefits (52.9%)'. The department where errors in the ICMIC occurred most frequently was the department for medical insurance claims in the hospital. CONCLUSION: The accuracy rate of the ICMIC was 83.0%.

A Study on the Medical Record Technicians Manpower Relation by Before and after Computerization of Medical Record / 대한의료정보학회지

This research investigated on the medical recorder manpower relation by before / after medical record computerization for the object of 51 hospitals in 1998 year. Judging from the situation before / after computerization shown on this investigation, the number of personnels was more increased since computer work than manual work, and the medical recorder present conditions by years show that they have been gradually increasing. This is considered why affairs diversely change according to computerization, the auxiliary recorder present conditions shows the reduction of 98 year in comparison with 94 year. This is regarded that personnels were reduced by facilities like existing transporting pipes. Accordingly, vast data are produced and utilized in the medical record department(room) too, therefore information will be quickly / correctly dealt for this. The times invested for simple affairs will be easily diminished by making existing simple affairs be computerized, and so personnels will have to be invested to earnestly / diversely utilize vast information not to reduce personnels in proportion to diminished times.