scholarly journals Using structured data entry systems in the electronic medical record to collect clinical data for quality and research: Can we efficiently serve multiple needs for complex patients with spina bifida?

2018 ◽  
Vol 11 (4) ◽  
pp. 303-309
Author(s):  
Jason P. Van Batavia ◽  
Dana A. Weiss ◽  
Christopher J. Long ◽  
Julian Madison ◽  
Gus McCarthy ◽  
...  
Keyword(s):  
Spina Bifida ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Clinical Data ◽  
Data Entry ◽  
Structured Data ◽  
Complex Patients

Consultation of Medical Narratives in the Electronic Medical Record

1999 ◽  
Vol 38 (04/05) ◽  
pp. 289-293 ◽  
Author(s):  
H. J. Tange
Keyword(s):  
Information Retrieval ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Data Entry ◽  
Daily Practice ◽  
Evaluation Study ◽  
System Level ◽  
Free Text ◽  
Patient Case ◽  
Medical Narratives

AbstractThis article presents an overview of a research project concerning the consultation of medical narratives in the electronic medical record (EMR). It describes an analysis of user needs, the design and implementation of a prototype EMR system, and the evaluation of the ease of consultation of medical narratives when using this system. In a questionnaire survey, 85 hospital physicians judged the quality of their paper-based medical record with respect to data entry, information retrieval and some other aspects. Participants were more positive about the paper medical record than the literature suggests. They wished to maintain the flexibility of data entry but indicated the need to improve the retrieval of information. A prototype EMR system was developed to facilitate the consultation of medical narratives. These parts were divided into labeled segments that could be arranged source-oriented and problem-oriented. This system was used to evaluate the ease of information retrieval of 24 internists and 12 residents at a teaching hospital when using free-text medical narratives divided at different levels of detail. They solved, without time pressure, some predefined problems concerning three voluminous, inpatient case records. The participants were randomly allocated to a sequence that was balanced by patient case and learning effect. The division of medical narratives affected speed, but not completeness of information retrieval. Progress notes divided into problem-related segments could be consulted 22% faster than when undivided. Medical history and physical examination divided into segments at organ-system level could be consulted 13% faster than when divided into separate questions and observations. These differences were statistically significant. The fastest divisions were also appreciated as the best combination of easy searching and best insight in the patient case. The results of our evaluation study suggest a trade-off between searching and reading: too much detailed segments will delay the consultation of medical narratives. Validation of the results in daily practice is recommended.

Automated Extraction of Structured Data from Text Notes in the Electronic Medical Record

2020 ◽  
Author(s):  
Alexander C. Flint ◽  
Ronald B. Melles ◽  
Jeff G. Klingman ◽  
Sheila L. Chan ◽  
Vivek A. Rao ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Structured Data ◽  
Automated Extraction

The Use of Focused Electronic Medical Record Forms to Improve Health-care Outcomes

2011 ◽  
Vol 101 (4) ◽  
pp. 331-334
Author(s):  
Bryan D. Caldwell ◽  
Robert D. Katz ◽  
Eugene M. Pascarella
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Clinical Data ◽  
Treatment Effectiveness ◽  
Case Series ◽  
Electronic Medical Record System ◽  
Record System ◽  
Medical Record System ◽  
Prospective Case Series ◽  
Walking Programs

Background: We tested the use of specifically designed electronic medical record forms, thereby demonstrating the ability to electronically capture, report, and compare clinical data. To that end, podiatric physicians can determine what constitutes the most effective program or treatment for specific conditions by documenting their treatment outcomes. Methods: A prospective case series was initiated to determine the value of using focused electronic medical record forms to track walking programs in the practices of podiatric physicians. Three patients were observed for 48 weeks using focused electronic medical record forms to input data (body mass index, cholesterol level, hemoglobin A1c level, blood pressure, and other vital information). Patients were given pedometers so that they could log their mileage and their podiatric physicians could enter it into the medical record. Information was collected using an electronic medical record system with the ability to link multiple templates together and assign logic to create flexible entry completion requirements. The clinical data generated are captured in a common database, where the data offer future opportunity to compare statistics among a multitude of practices in various demographic regions. Results: Focused electronic medical record forms were effectively used to track improvements and overall health benefits in a walking program supervised by podiatric physicians. Conclusions: Valuable information can be ascertained with focused electronic medical record forms to help determine treatment effectiveness. This information can later be compared with practices across many different demographics to ascertain the best evidence-based practice. (J Am Podiatr Med Assoc 101(4): 331–334, 2011)

Using electronic medical record system to improve compliance with national guidelines for comprehensive distress screening in cancer patients.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 309-309
Author(s):  
Chintan Pandya ◽  
Sandra Sabatka ◽  
Michelle Kettinger ◽  
Alexander Alongi ◽  
Lauren M. Hamel ◽  
...  
Keyword(s):  
Social Work ◽  
Cancer Patients ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Psychosocial Care ◽  
Structured Data ◽  
National Guidelines ◽  
Distress Screening ◽  
Oncology Care

309 Background: Psychosocial distress screening (DS) and management is associated with improved quality of life and outcomes in cancer patients and is required for accreditation by the American College of Surgeons Commission on Cancer. Comprehensive distress screening (CDS) consists of routine distress screening, evaluation, referral to appropriate psychosocial services, and follow-up to ensure adequate care. Electronic medical record (EMR) systems can be leveraged to facilitate and document CDS as part of clinical care and to evaluate the CDS process as a quality standard. The aim of this study is to develop and implement an EMR-based tool to document and evaluate the CDS process as part of routine oncology care. Methods: An EMR-based tool with structured data fields is developed for social workers to document risk factors for distress, assessment, management plan including psychosocial service referrals, and time spent delivering care following DS using the NCCN distress thermometer (DT). Evaluation of CDS process is done in cancer patients who have documented psychosocial care in the EMR-system from 1/2017-5/2018. Results: During the study period, 1327 cancer patients underwent 2480 distress screening evaluations. The average distress score was 3.2 (median = 2) on the DT scale of 0-10, with 855 (64%), 326 (25%), and 146 (11%) patients reporting on average mild (0-3), moderate (4-6), and severe (7-10) distress respectively. 400/1327 (30%) patients accounted for 1177 documented social work contact/visits, of which financial (40%) and emotional (15%) were the most common concerns. 89% (1047) of the visits had follow-up plans and 77% of encounters resulted in referrals, of which financial support (26%) and pharmacy assistance (22%) were the most common referral services. The average time spent on each psychosocial care visit was reported to be 21 minutes. Conclusions: EMR-based forms with structured data fields can be used to document and promote improved adherence to national guidelines for CDS as part of routine oncology care by facilitating data collection. Such tools can be leveraged to capture relevant data on impact of CDS on social work resource utilization.

A clinically useful diabetes electronic medical record: Lessons from the past; pointers toward the future

1996 ◽  
Vol 134 (1) ◽  
pp. 31-42 ◽  
Author(s):  
Colum Gorman ◽  
James Looker ◽  
Tom Fisk ◽  
William Oelke ◽  
David Erickson ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Data Entry ◽  
Clinical Encounter ◽  
Free Text ◽  
Diabetes Clinic ◽  
The Past ◽  
The Future ◽  
Patients With Diabetes ◽  
On Line

Gorman C, Looker J, Fisk T, Oelke W, Erickson D, Smith S, Zimmerman B. A clinically useful diabetes electronic medical record. Lessons from the past; pointers toward the future. Eur J Endocrinol 1996;134:31–42. ISSN 0804–4643 We have analysed the deficiencies of paper medical records in facilitating the care of patients with diabetes and have developed an electronic medical record that corrects some of them. The diabetes electronic medical record (DEMR) is designed to facilitate the work of a busy diabetes clinic. Design principles include heavy reliance on graphic displays of laboratory and clinical data, consistent color coding and aggregation of data needed to facilitate the different types of clinical encounter (initial consultation, continuing care visit, insulin adjustment visit, dietitian encounter, nurse educator encounter, obstetric patient, transplant patient, visits for problems unrelated to diabetes). Data input is by autoflow from the institutional laboratories, by desk attendants or on-line by all users. Careful attention has been paid to making data entry a point and click process wherever possible. Opportunity for free text comment is provided on every screen. On completion of the encounter a narrative text summary of the visit is generated by the computer and is annotated by the care giver. Currently there are about 7800 patients in the system. Remaining challenges include the adaptation of the system to accommodate the occasional user, development of portable laptop derivatives that remain compatible with the parent system and improvements in the screen structure and graphic display formats. Colum Gorman, Division of Endocrinology and Metabolism, Mayo Clinic, Rochester. MN. USA

scholarly journals Can Linked Electronic Medical Record and Administrative Data Help Us Identify Those Living with Frailty?

2020 ◽  
Vol 5 (1) ◽  
Author(s):  
Sabrina Wong ◽  
Alan Katz ◽  
Tyler Williamson ◽  
Alexander Singer ◽  
Sandra Peterson ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Administrative Data ◽  
Population Data ◽  
Sentinel Surveillance ◽  
Structured Data ◽  
Data Sources ◽  
Sociodemographic Characteristics ◽  
Surveillance Network ◽  
Functional Deficits

IntroductionFrailty is a complex condition that affects many aspects of a patients’ wellbeing and health outcomes. ObjectivesWe used available Electronic Medical Record (EMR) and administrative data to determine definitionsof frailty. We also examined whether there were differences in demographics or health conditionsamong those identified as frail in either the EMR or administrative data. MethodsEMR and administrative data were linked in British Columbia (BC) and Manitoba (MB) to identifythose aged 65 years and older who were frail. The EMR data were obtained from the CanadianPrimary Care Sentinel Surveillance Network (CPCSSN) and the administrative data (e.g. billing,hospitalizations) was obtained from Population Data BC and the Manitoba Population ResearchData Repository. Sociodemographic characteristics, risk factors, prescribed medications, use andcosts of healthcare are described for those identified as frail. ResultsSociodemographic and utilization differences were found among those identified as frail from theEMR compared to those in the administrative data. Among those who were >65 years, who hada record in both EMR and administrative data, 5%-8% (n=191 of 3,553, BC; n=2,396 of 29,382,MB) were identified as frail. There was a higher likelihood of being frail with increasing age andbeing a woman. In BC and MB, those identified as frail in both data sources have approximatelytwice the number of contacts with primary care (n=20 vs. n=10) and more days in hospital (n=7.2vs. n=1.9 in BC; n=9.8 vs. n=2.8 in MB) compared to those who are not frail; 27% (BC) and 14%(MB) of those identified as frail in 2014 died in 2015. ConclusionsIdentifying frailty using EMR data is particularly challenging because many functional deficits arenot routinely recorded in structured data fields. Our results suggest frailty can be captured along acontinuum using both EMR and administrative data.

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