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PubMed2003

An applied evaluation of SNOMED CT as a clinical vocabulary for the computerized diagnosis and problem list.

The use of a standardized controlled terminology allows diverse systems and applications throughout the enterprise to translate data. In developing a customized enterprise-wide vocabulary for clinical terminology, we implemented SNOMED CT as a base vocabulary, while facilitating the addition of site-specific clinical terms or concepts not represented in SNOMED CT. In this paper, we evaluate the breadth of SNOMED CT terms and concepts for the coding of diagnosis and problem lists by clinicians within a computerized physician order entry (CPOE) system. Clinicians selected diagnosis and problem list terms from a lexicon based on SNOMED CT, submitting requests for clinical terms that were not found in the controlled vocabulary. For each "missing" term, we assigned one of four mapping types, representing the relationship of this new terminology entry to the SNOMED CT reference terminology. Our results show that the majority of diagnosis/problem list terms (88.4%) were found in SNOMED CT. Of the 145 missing terms, only 20 represented significant concepts missing from SNOMED CT, resulting in concept coverage of 98.5%. Our results show that SNOMED CT is a relatively complete standardized terminology on which to base a vocabulary for the clinical problem list.

Abbreviations as Topic↗

PubMed2001

[Inspection of transfusion sites by the French Blood Establishment].

Blood transfusion was concerned by two important reforms. The first one followed the French law dated January 4th, 1993, which created the French Blood Agency, Agence française du Sang (AFS). The second reform followed the law dated July 1st, 1998, which founded the French national blood service and set up the Etablissement Français du Sang (EFS) as a unique operator, as well as the Agence Française de Sécurité Sanitaire des produits de Santé (AFS-SAPS) as the control instrument of blood cell products. There are several kinds of inspections concerning the production of products, the manufacturing of reagents, tissue banks, cellular therapy and product irradiation. The inspections are always followed by a report that points out malfunctions. The inspections may also lead to the issue of warning letters or official notifications. In those cases, it is the EFS chairman who directly answers to the general director of the AFSSaPS. Those inspections are supported by a close follow-up done by the EFS.

Blood Banks↗

PubMed2005

Inter-rater agreement in physician-coded problem lists.

Coded problem lists will be increasingly used for many purposes in healthcare. The usefulness of coded problem lists may be limited by 1) how consistently clinicians enumerate patients' problems and 2) how consistently clinicians choose a given concept from a controlled terminology to represent a given problem. In this study, 10 physicians reviewed the same 5 clinical cases and created a coded problem list for each case using UMLS as a controlled terminology. We assessed inter-rater agreement for coded problem lists by computing the average pair-wise positive specific agreement for each case for all 10 reviewers. We also standardized problems to common terms across reviewers' lists for a given case, adjusting sequentially for synonymy, granularity, and general concept representation. Our results suggest that inter-rater agreement in unstandardized problem lists is moderate at best; standardization improves agreement, but much variability may be attributable to differences in clinicians' style and the inherent fuzziness of medical diagnosis.

Forms and Records Control↗

PubMed2002

The methodical collection of ear surgery data as a basis for quality control.

Data relating to daily clinical practice were collected in an otologic database. Over a period of 3 years, information was gathered about 1,000 ear operations. This led to the following conclusions: the collection of data is difficult; the selection of data and the moment it should be fed into the systems are very important; there is a risk of using too many items and therefore reducing surgeon compliance. On the other hand, too few items result in irrelevant overviews. The collection of ear surgery data makes it easier to understand positive and negative outcomes.

Adult↗

PubMed1990

How to use continuous quality improvement theory and statistical quality control tools in a multispecialty clinic.

The management philosophy of continuous quality improvement (CQI) and the tools of statistical quality control (SQC) have the potential for advancing quality management in medicine as they have in industry. The authors report their favorable experience with the approach and explain how to adapt CQI principles and SQC charts and graphs, citing examples from their participation in a quality improvement effort in a multispecialty clinic serving a large hospital. The coupling of statistical techniques with modern approaches to outcome analysis may provide powerful tools not only for quality assurance and assessment but also for technology evaluation and resource allocation.

Data Collection↗

PubMedDate not supplied

Data processing system for the centre of nutrition and metabolic diseases.

The paper is devoted to the functional specification and the architecture of a data processing system to database generation and management within the Centre of Nutrition and Metabolic Diseases in Bucharest. The main operations performed by the system refer to: -Patient admission. A patient file which is created for any new patient, contains all the details hitherto included in the patient registration form. -File update, carried out periodically or whenever required. Any new relevant detail is added to the existing file in a conversational manner. -Report generation. The reports are produced periodically or upon request. -Inventory and stock control concerning the drugs dispensed free of charge. -Data processing and classification. -Creation and retrieval of patient archives. -Display on request of the various details contained by the patient file. The described system can be implemented on an INDEPENDENT 1-100 general purpose minicomputer, having a main memory of 96 words. The disc-based AMS operating system is used. The system operates in real time, although off-line background jobs can be run in order to assist the scientific work. A FORTRAN compiler is part of the operating system.

Computers↗

PubMed1999

Selection of instruments in the core set for DC-ART, SMARD, physical therapy, and clinical record keeping in ankylosing spondylitis. Progress report of the ASAS Working Group. Assessments in Ankylosing Spondylitis.

To select specific instruments for each domain of the core set for endpoints in ankylosing spondylitis (AS), we gathered all instruments described in the literature to assess the domains chosen as endpoints in AS and sent them to 43 members of the Assessments in Ankylosing Spondylitis (ASAS) Working Group. The following domains were taken into account: function, pain, spinal mobility, patient global assessment, morning stiffness, peripheral joints and entheses, acute phase reactants, x-ray spine, x-ray hips, fatigue. For each instrument the members were asked to judge if the instrument was feasible and relevant. If an instrument was judged to be not feasible or not relevant by more than 50% of the respondents the instrument was deleted from the list. These data were presented during an ASAS workshop and the final decisions were about which instruments to include in the core set. This process was repeated separately for the settings disease controlling antirheumatic therapy (DC-ART), symptom modifying antirheumatic drugs (SMARD) and physical therapy, and clinical record keeping. The response rate to the questionnaire was 72%. For each domain one or more instruments were selected, except for Entheses and Fatigue. The chosen instruments were similar for the 3 above settings. Core sets of specific instruments were selected for the OMERACT filter test for relevance and feasibility. For all these instruments the remaining aspects of the OMERACT filter (truth and discrimination) should be assessed by literature review and if needed by additional research. It is recommended to use these instruments in all research projects in AS.

Antirheumatic Agents↗

PubMed1992

COSHH (Control of Substances Hazardous to Health) in the NHS--beyond awareness: the practical assessment of risk.

This paper describes one approach to practical COSHH assessment developed for the (Scottish) Health Service. For completeness, the COSHH Regulations and corresponding Approved Code of Practice are reviewed from the point of view of undertaking a practical assessment of risk in hospitals. An assessment pro-forma developed for a Scottish Health Board is outlined. A hospital COSHH case study is briefly described. The training of health service COSHH assessors is considered. Finally, the need for a management approach to health and safety based on development and implementation of a suitable safety management system is proposed.

Forms and Records Control↗

PubMed2000

Point-of-care testing: inspection preparedness.

Point-of-care testing (POCT) in the operating room has changed dramatically since the implementation of the Clinical Laboratory Improvement Amendments (CLIA '88), which became effective in September 1992. With the implementation of CLIA '88, the Health Care Financing Administration (HCFA) mandated that human specimen testing 'for the purpose of diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of human beings', must be performed by a certified laboratory or testing site. To attain and maintain accreditation, the need for more stringent and comprehensive documentation has become imperative. The Joint Commission for the Accreditation of Hospitals (JCAHO), the College of American Pathologists (CAPS), HCFA, and state regulatory agencies require data such as staff credentialling, staff training/competency, procedure manuals, quality control logs, quality assurance/corrective action plans, correlation studies, proficiency testing results, and equipment maintenance logs to assure specimens are analyzed in a reliable manner by competent personnel so as not to jeopardize the safety and well being of the patient. Developing a comprehensive, ongoing survey readiness plan that includes a pre-survey checklist of all the documentation required and having this documentation in order and up to date well in advance of the survey will greatly enhance the probability of a successful survey conducted by the various regulatory agencies.

Accreditation↗

PubMed1986

How increased automation will improve the 1990 census of population and housing of the United States.

"The U.S. Bureau of the Census will increase significantly the automation of operations for the 1990 Census of Population and Housing, thus eliminating or reducing many of the labor-intensive clerical operations of past censuses and contributing to the speedier release of data products. An automated address control file will permit the computer to monitor the enumeration status of an address. The automated address file will also make it possible to begin electronic data processing concurrently with data collection, and, thus, 5-7 months earlier than for the 1980 Census. An automated geographic support system will assure consistency between various census geographic products, and computer-generated maps will be possible. Other areas where automation will be introduced or increased are questionnaire editing, coding of written entries on questionnaires, and reporting of progress and cost by field offices."

Americas↗

PubMed1989

Hyperthermia quality assurance guidelines.

These Hyperthermia Quality Assurance guidelines are a result of a joint workshop of the Hyperthermia Committee of the American College of Radiology and the Hyperthermia Physics Center, which is the national quality assurance program under Contract No. N01-CM-37512 with the National Cancer Institute. Hyperthermia technology presently lacks the kind of standardization in equipment, treatment procedures, patient monitoring, and treatment documentation available in radiotherapy. Therefore, preventing unacceptable variability in treatment data demands a strong commitment to in-house quality control procedures and to centralized quality assurance reviews in cooperative multi-institutional trials. This paper presents a set of test procedures necessary to ensure proper operation of equipment, suggests a frequency for such tests, and also includes guidelines on quality control procedures to be used during treatment to improve the safety, effectiveness, and reproducibility of hyperthermia treatments. A set of forms are presented to indicate the minimum data, albeit incomplete, that must be collected for acceptable documentation of treatment. These guidelines should be valuable not only to the new entrants in the field but also to those participating in multi-institutional cooperative hyperthermia trials. They have been approved by the Hyperthermia Committees of American College of Radiology, American Society for Therapeutic Radiology and Oncology, Radiation Therapy Oncology Group and the American Association of Physicists in Medicine.

Forms and Records Control↗

PubMedDate not supplied

[Safety forms for industrial lubricating oils: a working proposal at the national level].

The health and safety data sheets for lubricating oils currently in use present considerable differences regarding the information they provide. Often, the information is either too generalized or incomplete--particularly on the chemical aspects of oils--and therefore the sheets are inadequate for the prevention and control of the occupational risks. For the purposes of harmonization, a data sheet has been prepared which takes into account the specific features of the products, and particularly the handling of confidential data. The most important oil manufacturers have been consulted, and they have agreed to use the data sheet in order to provide information on their products to the local health authorities. The widespread use of this data sheet should enable an easier comparison of the health and safety data of oils to be made, provide a better understanding of the information received and, consequently, evaluate the risks involved.

Confidentiality↗

PubMed2001

A comparison of two methods for identifying surgical site infections following orthopaedic surgery.

Many infection control practitioners (ICPs) dedicate a significant amount of time and resources to surveillance of surgical site infections (SSIs). Alternative surveillance methods need to be explored to reflect the changes to the healthcare system and the increasing economic constraints placed on infection control units. This study was undertaken to compare two methods of identifying SSIs in orthopaedic surgery. Surveillance data collected routinely by ICPs was compared with data obtained from the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) coding in the medical record. Concordant results between the two methods were obtained. The use of ICD-9-CM coding, as stored in hospital patient administration system databases, has the ability to enhance routine surgical site surveillance programmes. These systems can be used as the basis for screening large data sets for SSIs and identifying where SSIs resulted in patient re-admission. A reduction in the duplication of data and time spent by the ICP on the collection of information for surveillance purposes can be achieved.

Forms and Records Control↗

PubMed2001

Establishing and running an effective telephone-based anticoagulation service.

Observational studies and randomized controlled trials have revealed improvement in international normalized ratio (INR) control and reduced thrombotic and hemorrhagic events in patients taking warfarin who are managed by an anticoagulation service (ACS) compared with traditional physician care. In this article, we describe how to establish a multidisciplinary telephone-based ACS to monitor INRs, dose warfarin, and heparin therapy, and to educate patients by telephone. We address how to improve ACS efficiency by using an electronic medical record, charting by exception, holding group-based education, communicating by telephone, and conducting quality assurance. We also make recommendations for improving the quality of care of patients taking anticoagulants that can be implemented in any setting and we discuss how to apply these guidelines to other remote disease-state management programs (eg, diabetes).

Anticoagulants↗

PubMed2005

Human and system errors, using adaptive turnaround documents to capture data in a busy practice.

Capturing coded clinical data for clinical decision support can improve care, but cost and disruption of clinic workflow present barriers to implementation. Previous work has shown that tailored, scannable paper forms (adaptive turnaround documents, ATDs) can achieve the benefits of computer-based clinical decision support at low cost and minimal disruption of workflow. ATDs are highly accurate under controlled circumstances, but accuracy in the setting of busy clinics with untrained physician users is untested. We recently developed and implemented such a system and studied rates of errors attributable to physician users and errors in the system. Prompts were used in 63% of encounters. Errors resulting from incorrectly marking forms occurred in 1.8% of prompts. System errors occurred in 7.2% of prompts. Most system errors were failures to capture data and may represent human errors in the scanning process. ATDs are an effective way to collect coded data from physicians. Further automation of the scanning process may reduce system errors.

Ambulatory Care Information Systems↗

PubMedDate not supplied

Enhancing performance measurement: NCQA's road map for a health information framework. National Committee for Quality Assurance.

Measuring the quality of health care delivery is one of the most critical challenges facing US health care. Performance measurement can be used to track the quality of care that health plans and medical groups deliver, but effective performance measurement requires timely access to detailed and accurate data. In 1996, the National Committee for Quality Assurance (NCQA) commissioned a report to learn what actions would improve health plans' capacity to electronically report performance data for the Health Plan Employer Data and Information Set (HEDIS). Tracking clinical performance will require not just clinical data stored in information systems, but an integrated health information framework. Seven features are essential to this framework: (1) it specifies data elements; (2) it establishes linkage capability among data elements and records; (3) it standardizes the element definitions; (4) it is automated to the greatest possible extent; (5) it specifies procedures for continually assessing data quality; (6) it maintains strict controls for protecting security and confidentiality of the data; and (7) it specifies protocols for sharing data across institutions under appropriate and well-defined circumstances. Health plans should anticipate the use of computerized patient records and prepare their data management for an information framework by (1) expanding and improving the capture and use of currently available data; (2) creating an environment that rewards the automation of data; (3) improving the quality of currently automated data; (4) implementing national standards; (5) improving clinical data management practices; (6) establishing a clear commitment to protecting the confidentiality of enrollee information; and (7) careful capital planning. Health care purchasers can provide the impetus for implementing the information framework if they demand detailed, accurate data on the quality of care.

Forms and Records Control↗

PubMed2002

Software for automating analysis of encoded combinatorial libraries.

This paper describes the applications which are used to automate the analysis of encoded combinatorial libraries. Commercial packages from MDL, Oracle and Agilent are linked with application software written in C/C++, in Microsoft Access and in ChemStation macro language. Encoding correspondence lists for each of up to three synthetic steps are conveniently associated with building block lists using the first application, CodeGen. The second application Decode allows the user to identify the individual beads picked onto a 96-well plate and the pool number for each bead. The decoding chromatography data for each well is then loaded into the program. The chromatography data is used to identify the tags used in the synthesis. Along with the building block information from ISIS/Host, the building block used in each step of the synthesis can be identified. A third routine, Code-to-Structure, takes the coded library building blocks and creates the connection table in ISIS for each structure found by the decode program. For quality control of encoded library synthesis, the decoded structures on a set of beads is compared to the LC/UV/MS data for the ligand cleaved from the same bead. CAPTURE, a GlaxoSmithKline proprietary application, is used to display and analyze the decoded structures and associated mass spectral data. This application uses simple isotopic composition and electrospray ionization rule sets to predict mass spectra and judge the concordance of a structure- mass spectrum data set. An ancillary program, EIC, is used to extract predicted single ion chromatograms from the full scan LC/MS data.

Combinatorial Chemistry Techniques↗

PubMed2005

MPEG-21 as an access control tool for the National Health Service Care Records Service.

Since the launch of the National Health Service (NHS) Care Records Service with plans to share patient information across England, there has been an emphasis on the need for manageable access control methods. MPEG-21 is a structured file format which includes an Intellectual Property Management and Protection (IPMP) function using XML to present all digitally stored items in the patient record. Using DICreator software, patient records consisting of written text, audio-recordings, non-X-ray digital imaging and video sequences were linked up successfully. Audio records were created using Talk-Back 2002 to standardize and optimize recording quality. The recorded reports were then linked and archived using iTunes. A key was used each time the file was displayed to secure access to confidential patient data. The building of the correct file structure could be monitored during the entire creation of the file. The results demonstrated the ability to ensure secure access of the MPEG-21 file by both health-care professionals and patients by use of different keys and a specific MPEG-21 browser. The study also showed that the enabling of IPMP will provide accurate audit trails to authenticate appropriate access to medical information.

Computer Security↗