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PubMed1999

Influences of the Unified Service Action Model on the HL7 Reference Information Model.

Modeling information for the electronic medical record (EMR) builds on a century of study on information and its relationship to cost and quality improvement. An initiative to examine the focus of cost and quality improvement and its relationship to information modeling resulted in the development of the Unified Service Action Model of healthcare processes, which focuses on the action as the center of cost accounting, quality accounting and privacy management. The application of this model to the HL7 Reference Information Model produced a simplification of the HL7 model at the cost of increased reliance on vocabulary terms for actions.

Costs and Cost Analysis↗
PubMed2001

Dynamic viewer of medical events in electronic medical record.

Medical record should enable doctors to comprehend the patient's history and select suitable medical treatment. In paper based medical records, medical events (examination, treatment etc.) are recorded successively, and problem oriented recording is difficult to be applied to patients with much information and a long history. Consequently it is not easy to understand the patient's history from paper based medical records. In order to solve this problem, we developed the flow sheet system in our electronic medical record (EMR). To make a flow sheet, we analyzed the structure of the medical event data. In this paper we introduced the medical event information model for our EMR. Furthermore, we clarified the specification of the data presentation on the flow sheet. We developed the flow sheet on the basis of these analyses. Because there are 3 layers in the vertical axis of the flow sheet, many items of the medical event can be displayed on the screen. When user clicks the cell, the corresponding detail data including images are shown. This system functions to link medical event items with a problem, and shows the bundled items on the flow sheet when the user selects the problem. We implemented this system in Osaka University Hospital. The number of the types of medical events and those of detail events in inpatients are 5.0+1.7 (mean+SD) and 60+47, respectively. The medical doctors in Osaka University Hospital evaluated this system, and concludes that the flow sheet data presentation makes comprehension of the patient's history easier than paper based records. As to the function of bundling the items relevant to the problem, they feel it is especially useful for patients with chronic disease. Thus the flow sheet data presentation in EMR is useful for medical practice.

Chronic Disease↗
PubMed2001

Toward a model for the evaluation of clinical coding systems.

OBJECTIVE: To demonstrate an empirical method to evaluate the utility of clinical coding systems. To use this method to assess the predictive power of two codes. METHOD: Controlled trial of two coding systems. SETTING: The Read Clinical Codes, version II and the International Classification of Primary Care (ICPC). OUTCOME MEASURES: The association between codes and pharmaceuticals prescribed. RESULTS: The power of both codes to predict pharmaceuticals increased with their precision. ICPC performed better than Read at the same level of precision. CONCLUSION: ICPC may be a more efficient coding system to use than Read. Assessment of the predictive power of a code is central to assessing its utility.

Diagnosis-Related Groups↗
PubMed2002

The index as a new concept towards an integrated framework for the electronic patient record.

OBJECTIVE: To overcome some classical limitations of the POMR (Problem-Oriented Medical Record), including the management of divergent opinions between health professionals, in order to construct a common patient record across multiple disciplines in hospital settings and professional networks. METHODS: Using a complex clinical case, we improved a POMR model previously used by GPs in order to translate it into a hospital setting. The enhanced model has been assessed through use in various ongoing clinical cases and through extended discussion with professional end-users (physicians, nurses, general practitioners, and social workers). RESULTS: The Index concept (flexible structural link) is proposed as a major improvement in the construction of a POMR in a shared care environment. CONCLUSIONS: The Index introduces interesting new perspectives. Following its implementation in the Belgian pilot site in the CORINES project, further studies remain to be carried out in order to develop a cost/benefit assessment.

Humans↗
PubMed2003

A generic model of clinical practice.

OBJECTIVES: Many shared-care projects feel the need for electronic patient-record (EPR) systems. In absence of practical experiences from paper record keeping, a theoretical model is the only reference for the design of these systems. In this article, we review existing models of individual clinical practice and integrate their useful elements. We then present a generic model of clinical practice that is applicable to both individual and collaborative clinical practice. METHODS: We followed the principles of the conversation-for-action theory and the DEMO method. According to these principles, information can only be generated by a conversation between two actors. An actor is a role that can be played by one or more human subjects, so the model does not distinguish between inter-individual and intra-individual conversations. RESULTS: Clinical practice has been divided into four actors: service provider, problem solver, coordinator, and worker. Each actor represents a level of clinical responsibility. Any information in the patient record is the result of a conversation between two of these actors. Connecting different conversations to one another can create a process view with meta-information about the rationale of clinical practice. Such process view can be implemented as an extension to the EPR. CONCLUSIONS: The model has the potential to cover all professional activities, but needs to be further validated. The model can serve as a theoretical basis for the design of EPR-systems for shared care, but a successful EPR-system needs more than just a theoretical model.

Communication↗
PubMed2003

Managers see the problems associated with coding clinical data as a technical issue whilst clinicians also see cultural barriers.

OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. RESULTS: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. CONCLUSIONS: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients' views may help clarify the magnitude of this barrier.

Ambulatory Care Information Systems↗
PubMed2003

Measuring the completeness and currency of codified clinical information.

OBJECTIVES: The paper describes how an objective score (CCscore) of the 'completeness' and 'currency' of codified clinical information relevant to the management of diabetes mellitus may be derived for individual practices. METHODS: A questionnaire was developed and administered to 35 practices and statistical methods were used to test for correlation between the prevalence for diabetes mellitus and the relevant CCscores RESULTS: No significant correlation could be found. CONCLUSIONS: The 'quality' of computer-stored information varies widely across English General practices for reasons that are incompletely understood. We demonstrated how CCscores may be calibrated for different 'views' of 'relevance', 'completeness', and 'currency' and yet be consistent across practices for a given 'view'. The potential value of this score and how it may contribute to our understanding of variation in 'information quality' are discussed.

Benchmarking↗
PubMed2003

"We fill in our working understanding": on codes, classifications and the production of accurate data.

OBJECTIVES: This paper describes differences in the way general practitioners in Denmark, The Netherlands and Great Britain make codes fit into the local conditions under which they work. METHODS: An ethnographic study method has been used to collect data in Dutch, British and Danish general practices. RESULTS AND CONCLUSIONS: The paper argues that what counts as "accurate data" is locally constructed. As codes are produced in local networks of human and technological actors, the way accuracy is constructed is dependent on the extra work that is carried out (by actors inside the clinic as well as outside of it). On the basis of differences between coding practices and classification systems the paper discusses how inherent tensions between coding for primary and secondary purposes can be solved. The paper concludes that instead of evaluating data in terms of how accurate they are in general, they should be looked at in terms of pertinence to specific research questions.

Denmark↗
PubMed2003

Medical problem and document model for natural language understanding.

We are developing tools to help maintain a complete, accurate and timely problem list within a general purpose Electronic Medical Record system. As a part of this project, we have designed a system to automatically retrieve medical problems from free-text documents. Here we describe an information model based on XML (eXtensible Markup Language) and compliant with the CDA (Clinical Document Architecture). This model is used to ease the exchange of clinical data between the Natural Language Understanding application that retrieves potential problems from narrative document, and the problem list management application.

Computer Simulation↗
PubMed1992

A computerised out-patient medical records programme based on the Summary Time-Oriented Record (STOR) System.

Advances in microcomputer hardware and software technology have made computerised outpatient medical records practical. We have developed a programme based on the Summary Time-Oriented Record (STOR) system which complements existing paper-based record keeping. The elements of the Problem Oriented Medical Record (POMR) System are displayed in two windows within one screen, namely, the SOAP (Subjective information, Objective information, Assessments and Plans) elements in the Reason For Encounter (RFE) window and the problem list with outcomes in the Problem List (PL) window. Context sensitive child windows display details of plans of management in the RFE window and clinical notes in the PL window. The benefits of such innovations to clinical decision making and practice based research and its medico-legal implications are discussed.

Humans↗
PubMed2004

Forms that Inform.

OBJECTIVES: Sound medical decisions are easier for clinicians who have essential patient data in the right place at the right time. Our goal was to develop a usable form to guide clinical decisions and then test it using actual cases. METHODS: The authors designed a form to represent data from patients with chest pain; it was revised several times. We incorporated opinions from clinician-users as well as evidence from the literature to improve usability. To test the design, we filled out forms with actual patient data derived from Emergency Department charts of patients who presented with chest pain. We then validated the design by having house officer reviewers make the decision to admit, observe in the ER for one day, or discharge subjects based entirely on a one-page form. RESULTS: Thirty-three house officers reviewed our initial design and made suggestions. Our literature search yielded a number of factors discriminating ischemic from non-ischemic chest pain. Sixteen factors were included on a finalized form in the rank order assigned by reviewing physicians. Over 4 days, data from 29 subjects were used to fill out copies of the form. Based purely on the completed forms, house officers made decisions to admit, discharge, or observe all 29 subjects in less than 30 minutes. CONCLUSIONS: Forms have traditionally been employed to record and organize data. Here we show how principles of usability engineering can be used to create a form to meet the needs of users and even encourage evidence-based practice.

Chest Pain↗
PubMed2004

Evaluation of SNOMED coverage of Veterans Health Administration terms.

Veterans Health Administration (VHA) is now evaluating use of SNOMED-CT. This paper reports the first phase of this evaluation, which examines the coverage of SNOMED-CT for problem list entries. Clinician expressions in VA problem lists are quite diverse compared to the content of the current VA terminology Lexicon. We selected a random set of 5054 narratives that were previously "unresolved" against the Lexicon. These narratives were mapped to SNOMED-CT using two automated tools. Experts reviewed a subset of the tools' matched, partly matched, and un-matched narratives. The automated tools produced exact or partial matches for over 90% of the 5054 unresolved narratives. SNOMED-CT has promise as a coding system for clinical problems. In subsequent studies, VA will examine the coverage of SNOMED for other clinical domains, such as drugs, allergies, and physician orders.

Forms and Records Control↗
PubMed2004

Automated medical problem list generation: towards a patient timeline.

The problem-oriented electronic medical record has been investigated as an alternative to source-oriented organization of patient data. At the core of a problem-oriented view is the medical problem list. Maintenance of the medical problem list is often manual, making it highly user dependent. We detail the beginnings of an automated medical problem list generator based on ICD-9: given a set of ICD-9 codes associated with a patient record, the system maps the codes (and related data) to an anatomy-centric hierarchy. 1 million patient encounters from an outpatient setting were reviewed to generate a unique set of 7,890 ICD-9 codes. Natural language processing of the ICD-9 string descriptions identified 1,981 anatomical terms, which were subsequently mapped to one of 21 anatomical categories. The output of the medical problem list generator was then used to create a problem-oriented, gestalt view of a patient's medical record. Preliminary evaluation of the generator revealed 100% recall, but only 60% precision. This initial work has highlighted several issues in defining a medical problem list, including questions of granularity and performance trade-offs.

Electronic Data Processing↗
PubMed2002

A problem-oriented, knowledge-based patient record system.

The concept of a problem-oriented patient record was presented in the late 1960s but has yet to gain wide acceptance. In this paper we suggest a distinction between the idea of problem orientation and the implementation of the idea. We argue that the problem-oriented patient record offers an intuitive and useful way to work with patient information. We show that the concept of problem-oriented patient records facilitates better care of patients by supporting continuity of care, removing redundant and confusing information, and enabling easy overview of and access to its content. We further propose a two-layer framework that has knowledge of its content and use and is able to better utilize information in the record by presenting relevant information to the user at a time when needed. Conceptually, this is done by adding a layer of knowledge to the patient record system: 1) Knowledge about physicians' way of thinking and working, 2) Their corresponding information use and need during patient care, and 3) Tools to determine information relevance in a given situation; such a knowledge-based system is able to reason with its content and use.

Artificial Intelligence↗