Sincerity in bulk.

This paper is concerned with situations in which a speaker issues many speech acts at the same time. A common example is the publication of a large text such as a book containing many distinct assertions. It is argued that these cases present a challenge for speech act theory related to how we are to understand sincerity. With reference to the well known paradox of the preface, it is argued that sincerity of such bulk speech cannot be understood as a simple conjunction of the sincerity of the encoded acts. A proposal is given according to which sincere bulk speech requires the speaker explicitly and as precisely as possible mark any subsets of her communication about which she has doubts.

Sincerely, Anonymous.

This paper provides an account of anonymous speech treated as anonymized speech. It is argued that anonymous speech acts are best defined by reference to intentional acts of blocking a speaker's identification as opposed to the various epistemic effects that imperfectly correlate with these actions. The account is used to examine two important subclasses of anonymized speech: speech using pseudonyms, and speech anonymized in a specifically communicative manner. Several pragmatic and ethical issues with anonymized speech are considered.

Synoptic operative reports for spinal cord injury patients as a tool for data quality.

The advent of synoptic operative reports has revolutionized how clinical data are captured at the time of care. In this article, an electronic synoptic operative report for spinal cord injury was implemented using interoperable standards, HL7 and Systematized Nomenclature of Medicine-Clinical Terms. Subjects (N = 10) recruited for a pilot study completed recruitment and feedback questionnaires, and produced both an electronic synoptic operative report for spinal cord injury report and a dictated narrative operative report for an actual patient case. Results indicated heterogeneity by subjects in access and use of electronic sources of patient data. Feedback questionnaire results confirmed that subjects were comfortable using both methods for data entry of operative reports, and that some were unable to find the diagnosis terms they needed in electronic synoptic operative report for spinal cord injury. Data quality improved. Electronic synoptic operative report for spinal cord injury reports were more complete (95.26%) than dictated (80%) for all subjects. An accuracy assessment, which considered usability for secondary data use, was conducted and the electronic synoptic operative report for spinal cord injury was demonstrated to improve accuracy.

Design and implementation of synoptic operative report template using interoperable standards.

The increasing use of synoptic operative reports in clinical settings represents a major milestone in the advancement of health information technology. Synoptic operative report templates enable clinicians to capture and display succinct clinical information in a standardized and logical manner. Synoptic operative report templates also provide the optimum goal of enriching personalized health information of a given patient at the point of care so as to support the exchange of clinical information across the continuum of multiple healthcare providers. However, most of the available synoptic operative report templates in many clinical settings do not incorporate interoperable standards in their design and implementation. This paper proposes a novice template (i.e., eSOR-SCI) that uses interoperable standards for its design and implementation.

Systematized nomenclature of medicine clinical terms (SNOMED CT) to represent computed tomography procedures.

OBJECTIVE: To evaluate the ability of systematized nomenclature of medicine clinical terms (SNOMED CT) to represent computed tomography procedures in computed tomography dictionaries used in the Canadian province of Newfoundland and Labrador. METHODS: This study was conducted in two stages. In the first stage computed tomography dictionaries were collected and consolidated to one master list. The duplicated procedure names were deleted from the list. In the second stage the unique data items from the master list were matched with the SNOMED CT concepts. Sensitivity, specificity, and positive and negative predictive values of SNOMED CT were investigated. RESULTS: After eliminating 680 duplicate procedures from the total of 833, the study sample consisted of 153 data items. For pre-coordination, SNOMED CT had sensitivity of 56% and for post-coordination SNOMED CT had sensitivity of 98%. CONCLUSION: Our results suggest that SNOMED CT is a valid nomenclature for representing computed tomography procedures.

A conceptual framework for analyzing how Canadian physicians are using electronic medical records in clinical care.

Our electronic medical record (EMR) case study research pursued a set of questions to provide Canadian physicians with practical information on best practices and lessons learned regarding implementation and use of EMRs in ambulatory clinical care. The study's conceptual framework included an EMR System and Use Assessment Survey, interview guide, transcription codes, observation guide and case study report template. The common message that emerged was that no clinic would return to paper-based charts after experiencing the benefits of EMR. In seeking to corroborate our findings with success factors in an EMR implementation meta-framework, we further investigated the role of information incentives as a key factor in sustainable EMR implementations. The sections of our conceptual framework that best enabled us to capture information incentives were the 12 survey questions about information quality, EMR adoption questions in the interview guide and a subset of 26 items from our transcription coding scheme that were linked to physicians quotations about knowing more about the patient when using the EMR than when using paper.

The evolution and uptake of a drug information system: the case of a small Canadian province.

In 2008 the province of PEI, Canada implemented a province-wide, web-based drug information system for the purpose of improving patient safety. An evaluation study using grounded theory examined the human and workflow impact. Results indicated a need for great attention to the details of change management during implementation, including: ensuring application quality of all informational and technical elements, just-in-time training and technical support, on-site preparation for changed workflow processes, and collaboration among all stakeholders throughout.

Topic maps for exploring nosological, lexical, semantic and HL7 structures for clinical data.

A topic map is implemented for learning about clinical data associated with a hospital stay for patients diagnosed with chronic kidney disease, diabetes and hypertension. The question posed is: how might a topic map help bridge perspectival differences among communities of practice and help make commensurable the different classifications they use? The knowledge layer of the topic map was generated from existing ontological relationships in nosological, lexical, semantic and HL7 boundary objects. Discharge summaries, patient charts and clinical data warehouse entries rectified the clinical knowledge used in practice. These clinical data were normalized to HL7 Clinical Document Architecture (CDA) markup standard and stored in the Clinical Document Repository. Each CDA entry was given a subject identifier and linked with the topic map. The ability of topic maps to function as the infostructure ;glue' is assessed using dimensions of semantic interoperability and commensurability.

HealthInfoCDA: Case Composition Using Electronic Health Record Data Sources.

HealthInfoCDA denotes a health informatics educational intervention for learning about the clinical process through use of the Clinical Document Architecture (CDA). We hypothesize those common standards for an electronic health record can provide content for a case base for learning how to make decisions. The medical record provides a shared context to coordinate delivery of healthcare and is a boundary object that satisfies the informational requirement of multiple communities of practice. This study transforms clinical narrative in three knowledge-rich modalities: case write-up, patient record and online desk reference to develop a case base of experiential clinical knowledge useful for medical and health informatics education. Our ultimate purpose is to aggregate concepts into knowledge elements for case-based teaching.

Undocumented patient information: an impediment to quality of care.

PURPOSE: Poor documentation in medical records might reduce the quality of care and undermine analyses based on retrospective chart reviews. We assessed the documentation of cardiac risk factors and cardiac history in the records of patients hospitalized with myocardial infarction or heart failure. METHODS: We performed a retrospective cohort study involving direct chart audit of all consecutive hospitalizations for myocardial infarction (n = 2,109) or heart failure (n = 3,392) in Nova Scotia, Canada, from October 15, 1997, to October 14, 1998. The main outcome measures were the documentation rates for prespecified clinical items, including cardiac risk factors and history of myocardial infarction or heart failure, which were recognized as indicators of the quality of care for the conditions under study. RESULTS: Information was not documented in a high proportion of cases, ranging from 9% (smoking) to 58% (previous history of heart failure) in charts from patients hospitalized for myocardial infarction, and from 19% (smoking) to 69% (hyperlipidemia) in charts from heart failure hospitalizations. Lack of documentation was more common in women and the elderly. CONCLUSION: Documentation of important clinical information is poor even in the hospital charts of patients with severe conditions. This quality-of-care issue has implications for health services and outcomes research, including the development of report cards.