Anesthesia Information Management Systems: Evolution of the Paper Anesthetic Record to a Multisystem Electronic Medical Record Network That Streamlines Perioperative Care.

Initially devised in the 1890s, the traditional anesthetic record comprises physiological changes, crucial anesthetic or surgical events, and medications administered during the perioperative period. The timely collection of quality data facilitates situational awareness and point-of-care clinical decision making. The burgeoning volume and complexity of data in conjunction with financial incentives and the push for improved clinical documentation by regulatory bodies have prompted the transition away from paper records. Anesthesia Information Management Systems (AIMS) are specialized electronic health record networks that allow the anesthesia record to interface with hospital clinical data repositories, resulting in improvements in quality of care, patient safety, operations management, reimbursement, and translational research. Like most new technological advances, adoption was slow at first due to the challenges of integrating complex systems into daily clinical practice, questions about return on investment, and medicolegal liability. Recent technological advances, coupled with government incentives, have allowed AIMS adoption to reach an acceleration phase among US academic medical centers; widespread utilization of AIMS by 84% of US academic medical centers is expected by 2018-2020. Adoption among nonacademic US and European medical centers still remains low; information concerning Asian countries is limited to literature describing only single-hospital center experiences.

Rochester Epidemiology Project Data Exploration Portal.

INTRODUCTION: The goal of this project was to develop an interactive, web-based tool to explore patterns of prevalence and co-occurrence of diseases using data from the expanded Rochester Epidemiology Project (E-REP) medical records-linkage system. METHODS: We designed the REP Data Exploration Portal (REP DEP) to include summary information for people who lived in a 27-county region of southern Minnesota and western Wisconsin on January 1, 2014 (n = 694,506; 61% of the entire population). We obtained diagnostic codes of the International Classification of Diseases, 9th edition, from the medical records-linkage system in 2009 through 2013 (5 years) and grouped them into 717 disease categories. For each condition or combination of 2 conditions (dyad), we calculated prevalence by dividing the number of persons with a specified condition (numerator) by the total number of persons in the population (denominator). We calculated observed-to-expected ratios (OERs) to test whether 2 conditions co-occur more frequently than would co-occur as a result of chance alone. RESULTS: We launched the first version of the REP DEP in May 2017. The REP DEP can be accessed at http://rochesterproject.org/portal/. Users can select 2 conditions of interest, and the REP DEP displays the overall prevalence, age-specific prevalence, and sex-specific prevalence for each condition and dyad. Also displayed are OERs overall and by age and sex and maps of county-specific prevalence of each condition and OER. CONCLUSION: The REP DEP draws upon a medical records-linkage system to provide an innovative, rapid, interactive, free-of-charge method to examine the prevalence and co-occurrence of 717 diseases and conditions in a geographically defined population.

Clinical Information Systems - From Yesterday to Tomorrow.

OBJECTIVES: To review the history of clinical information systems over the past twenty-five years and project anticipated changes to those systems over the next twenty-five years. METHODS: Over 250 Medline references about clinical information systems, quality of patient care, and patient safety were reviewed. Books, Web resources, and the author's personal experience with developing the HELP system were also used. RESULTS: There have been dramatic improvements in the use and acceptance of clinical computing systems and Electronic Health Records (EHRs), especially in the United States. Although there are still challenges with the implementation of such systems, the rate of progress has been remarkable. Over the next twenty-five years, there will remain many important opportunities and challenges. These opportunities include understanding complex clinical computing issues that must be studied, understood and optimized. Dramatic improvements in quality of care and patient safety must be anticipated as a result of the use of clinical information systems. These improvements will result from a closer involvement of clinical informaticians in the optimization of patient care processes. CONCLUSIONS: Clinical information systems and computerized clinical decision support have made contributions to medicine in the past. Therefore, by using better medical knowledge, optimized clinical information systems, and computerized clinical decision, we will enable dramatic improvements in both the quality and safety of patient care in the next twenty-five years.

Bringing science to medicine: an interview with Larry Weed, inventor of the problem-oriented medical record.

Larry Weed, MD is widely known as the father of the problem-oriented medical record and inventor of the now-ubiquitous SOAP (subjective/objective/assessment/plan) note, for developing an electronic health record system (Problem-Oriented Medical Information System, PROMIS), and for founding a company (since acquired), which developed problem-knowledge couplers. However, Dr Weed's vision for medicine goes far beyond software--over the course of his storied career, he has relentlessly sought to bring the scientific method to medical practice and, where necessary, to point out shortcomings in the system and advocate for change. In this oral history, Dr Weed describes, in his own words, the arcs of his long career and the work that remains to be done.

History of PACS in Asia.

First, history of PACS (picture archiving and communication system for medical use) in Japan is described in two parts: in part 1, the early stage of PACS development from 1984 to 2002, and in part 2 the matured stage from 2002 to 2010. PACS in Japan has been developed and installed by local manufacturers by their own technology and demand from domestic hospitals. Part 1 mainly focuses on quantitative growth and part 2 on qualitative change. In part 2, integration of PACS into RIS (radiology information system), HIS (hospital information system), EPR (electronic patient record), teleradiology and IHE (integrating healthcare enterprise) is reported. Interaction with other elements of technology such as moving picture network system and three dimensional display is also discussed. Present situation of main 4 large size hospitals is presented. Second, history of PACS in Korea is reported. Very acute climbing up of filmless PACS diffusion was observed from 1997 to 2000. The reasons for such evolution are described and discussed. Also changes of PACS installation and system integration with other systems such as HIS and role of them in radiological diagnoses in Korea since 2002 are described. Third, history in China is investigated by checking international academic journals in English and described as far as events are logically linked and consistently meaningful.

The history of the Read Codes: the inaugural James Read Memorial Lecture 2011.

General practitioner (GP) computing has its origins in the 1970s when the benefits of clinical coding and prescribing were demonstrated. During the early 1980s Dr James Read, working with Abies Informatics Ltd, developed the eponymous Read Codes, which were broader and more comprehensive than other schemes, yet intuitive and easy to use. In 1988 a joint working party of the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) recommended that the Read Codes be adopted nationally. The Read Codes have been used by almost all GPs in the UK since the mid-1990s. Many developments in general practice, including GP fundholding (where GPs held the budgets to commission elective care for their patients), the Quality and Outcomes Framework (QOF - pay for performance for improving chronic disease management) and GP commissioning (the current NHS reform in which primary care leads commissioning of services for their patients) would have been impossible without all GPs using a common clinical coding scheme. Systematized Nomenclature For Medicine - Clinical Terms (SNOMED CT) is a merger of the Read Codes with SNOMED RT - the original SNOMED reference terminology developed by the American College of Pathologists.

Informação para a área de saúde: prontuário do paciente, ontologia de imagem, terminologia, legislação e gerenciamento eletrônico de documentos / Information for health area: promptuary of the patient, ontology of image, terminology, legislation and electronic document management

Esta coleção de textos que trata do prontuário do paciente, da ontologia de imagens medicais, da legislação arquivística em saúde e do gerenciamento eletrônico de documentos, incluindo imagens, joga luz sobre importantes temas para implantação do registro eletrônico em saúde. O Registro Eletrônico em Saúde é uma ferramenta importante para garantir a efetivação do direito a saúde. Na década de 80 o fim da exigência da 'carteirinha do INAMPS' para ter direito a atendimento foi um dos marcos importantes na luta pela universalização do direito a saúde. Não faria sentido nos dias de hoje, reestabelecer um cartão para ter acesso aos serviços de saúde, recriando a barreira procedimental. Por isso, o Cartão SUS é hoje visto como uma ferramenta para implantação do registro eletrônico em saúde, em especial permitindo a cada cidadão brasileiro ter um Prontuário Eletrônico do Paciente (PEP) que caminha na direção apontada nessa coletânea. (AU)

Informação para a área de saúde: prontuário do paciente, ontologia de imagem, terminologia, legislação e gerenciamento eletrônico de documentos / Information for health area: promptuary of the patient, ontology of image, terminology, legislation and electronic document management

Esta coleção de textos que trata do prontuário do paciente, da ontologia de imagens medicais, da legislação arquivística em saúde e do gerenciamento eletrônico de documentos, incluindo imagens, joga luz sobre importantes temas para implantação do registro eletrônico em saúde. O Registro Eletrônico em Saúde é uma ferramenta importante para garantir a efetivação do direito a saúde. Na década de 80 o fim da exigência da 'carteirinha do INAMPS' para ter direito a atendimento foi um dos marcos importantes na luta pela universalização do direito a saúde. Não faria sentido nos dias de hoje, reestabelecer um cartão para ter acesso aos serviços de saúde, recriando a barreira procedimental. Por isso, o Cartão SUS é hoje visto como uma ferramenta para implantação do registro eletrônico em saúde, em especial permitindo a cada cidadão brasileiro ter um Prontuário Eletrônico do Paciente (PEP) que caminha na direção apontada nessa coletânea.

A decade of data linkage in Western Australia: strategic design, applications and benefits of the WA data linkage system.

OBJECTIVES: The report describes the strategic design, steps to full implementation and outcomes achieved by the Western Australian Data Linkage System (WADLS), instigated in 1995 to link up to 40 years of data from over 30 collections for an historical population of 3.7 million. Staged development has seen its expansion, initially from a linkage key to local health data sets, to encompass links to national and local health and welfare data sets, genealogical links and spatial references for mapping applications. APPLICATIONS: The WADLS has supported over 400 studies with over 250 journal publications and 35 graduate research degrees. Applications have occurred in health services utilisation and outcomes, aetiologic research, disease surveillance and needs analysis, and in methodologic research. BENEFITS: Longitudinal studies have become cheaper and more complete; deletion of duplicate records and correction of data artifacts have enhanced the quality of information assets; data linkage has conserved patient privacy; community machinery necessary for organised responses to health and social problems has been exercised; and the commercial return on research infrastructure investment has exceeded 1000%. Most importantly, there have been unbiased contributions to medical knowledge and identifiable advances in population health arising from the research.

Living without a data management system.

The implementation of a typical electronic data capture (EDC) system for clinical trials - encompassing data entry, validation and reporting tools - involves modeling electronic case report forms (eCRFs) for data that will be entered by investigative trial sites, providing web access for the sites to enter the data, managing a 'cleaning and locking' process (in which any queries against the data are resolved), and transmitting the final data to SAS datasets. Other clinical data not included in CRFs, such as laboratory data, are typically handled in a separate clinical data management system; this information is not directly linked back to the trial sites and therefore is inaccessible for review. Thus, activities such as seeking site feedback on out-of-range laboratory values can only be performed by manually transcribing queries from the data management system into the EDC system. As the number of studies using EDC systems escalates and the number of studies gathering data on paper diminishes, the inefficiencies of handling data across different systems are becoming increasingly apparent. This article explores the opportunities, risks and technical requirements needed for an integrated EDC environment to enable a discontinuation of the use of older data management systems.

A brief history of nursing informatics in the United States of America.

From the beginning of modern nursing, data from standardized patient records were seen as a potentially powerful resource for assessing and improving the quality of care. As nursing informatics began to evolve in the second half of the 20th century, the lack of standards for language and data limited the functionality and usefulness of early applications. In response, nurses developed standardized languages, but until the turn of the century, neither they nor anyone else understood the attributes required to achieve computability and semantic interoperability. Collaboration across disciplines and national boundaries has led to the development of standards that meet these requirements, opening the way for powerful information tools. Many challenges remain, however. Realizing the potential of nurses to transform and improve health care and outcomes through informatics will require fundamental changes in individuals, organizations, and systems. Nurses are developing and applying informatics methods and tools to discover knowledge and improve health from the molecular to the global level and are seeking the collective wisdom of interdisciplinary and interorganizational collaboration to effect the necessary changes. NOTE: Although this article focuses on nursing informatics in the United States, nurses around the world have made substantial contributions to the field. This article alludes to a few of those advances, but a comprehensive description is beyond the scope of the present work.

Changes in Medical Documentation over the Last Five Decades.

In medical documentation, standardized coding schemes are used to facilitate sharing, transformation and reusability of data. First, classification systems coding schemes have been introduced. While classification systems are mainly used for statistical purposes, individual care documentation moves towards the use of nomenclatures coding schemes. The paper presents an overview of the development of coding schemes. Different coding schemes serve different purposes. Multiaxial schemes are the way of choice for comprehensively documenting complex care processes. There is a movement from mono-hierarchical classification systems to concept-based, multi-purpose and multi-hierarchical terminologies.

Integrating knowledge-based resources into the electronic health record: history, current status, and role of librarians.

Satisfying clinical information needs remains a major challenge in medicine, underscored by recent studies showing high medical error rates and suboptimal physician adherence to evidence-based practice guidelines. Advanced clinical decision support systems can improve practitioner performance and patient outcomes. Similarly, integrating online information resources into electronic health records (EHRs) shows great potential for positively impacting health care quality. This paper explores the evolution and current status of knowledge-based resource linkages within EHRs, including the benefits and drawbacks, as well as the important role librarians can play in this process.

Electronic patient records and their benefit for patient care. Findings from the Section on Patient Records.

OBJECTIVES: To summarize current excellent research in the field of patient records. METHOD: Synopsis of the articles selected for the IMIA Yearbook 2006. RESULTS: Current research in the field of patient records analyses users' needs and attitudes as well as the potential and limitations of electronic patient record systems. Particular topics are the questions physicians have when assessing patients during ward rounds, the timeliness of results when ordered electronically, the quality of documenting haemophilia home therapy, attitudes towards patient access to health records and adequate strategies for record linkage in dependence on the intended purpose. CONCLUSIONS: The best paper selection of articles on patient records shows examples of excellent research on methods used for the management of patient records and for processing their content as well as assessing the potential, limitations of and user attitudes towards electronic patient record systems. Computerized patient records are mature, so that they can contribute to high quality patient care and efficient patient management.

From punched cards to computerized patient records: a personal journey.

OBJECTIVES: This paper presents the early history of the development of CPR in Sweden, the importance of international cooperation and standardisation and how this cooperation has been facilitated by IMIA, the European Union and the standards organisations. It ends with the lessons learned after 35 years of experience put together by the Swedish Institute for Health Services Development, SPRI, in a 5 year project initiated by the Swedish Government and with participation of most health care providers in the country. METHODS: Starting with the first attempts to use punched cards to store and use patient information for clinical use the author describes his troublesome and difficult road to a Computerized Patient Record that could be used both for the work with the patient and as a tool to follow up both the diagnostic and therapeutic processes and for clinical research. RESULTS: The most important results of the efforts to develop a computerized patient record in Sweden are published in many reports, among them three SPRI reports published in the late 1990s, and they are: Standardized information architecture, a common terminology, rules for communication, security and safety, electronic addresses to all units and users and an agreed upon patient and user identification. CONCLUSIONS: The future CPR must be problem oriented, capable of only adding new information instead of repeating already-known data and be available in real time regardless of geographic location. It must be possible to present the information in the CPR as 'views' where the healthcare provider has stated in advance the information needed for his patients. There can be a number of 'views' for different occasions.