scholarly journals openEHR Based Contextual Problem List

2021 ◽  
Author(s):  
John Meredith ◽  
Ian McNicoll ◽  
Nik Whitehead ◽  
Michael Dacey
Keyword(s):  
Medical Record ◽  
Patient Record ◽  
Problem List ◽  
Problem Lists ◽  
Modelling Approach

The problem list is a key facet of the digital patient record that has historically been difficult to curate. This paper presents an implementation of a contextual problem list using openEHR. It describes the modelling approach, key model elements, and how these are assembled to underpin a Problem Oriented Medical Record. Finally, it discusses issues associated with how problem lists may be used.

Abstract 173: A Comparison of Administrative Claims Discharge Diagnosis with Electronic Medical Record Problem List in the Diagnosis of Acute Myocardial Infarction

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Michael D McCulloch ◽  
Tim Sobol ◽  
Joy Yuhas ◽  
Bill Ahern ◽  
Eric D Hixson ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Medical Record ◽  
Chart Review ◽  
Claims Data ◽  
Administrative Claims ◽  
Problem List ◽  
Principal Diagnosis ◽  
Administrative Claims Data ◽  
Patient Admissions

Background: Administrative claims data are commonly used for measurement of mortality and readmissions in Acute Myocardial Infarction (AMI). With advent of the Electronic Medical Record (EMR), the electronic problem list offers new ways to capture diagnosis data. However, no data comparing the accuracy of administrative claims data and the EMR problem list exists. Methods: Two years of admissions at a single, quaternary medical center were analyzed to compare the presence of AMI diagnosis in administrative claims and EMR problem list data using a 2x2 matrix. To gain insights into this novel method, 25 patient admissions were randomly selected from each group to undergo physician chart review to adjudicate a clinical diagnosis of myocardial infarction based on the universal definition. Results: A total of 105,929 admissions from January 1, 2010 to December 31, 2011 were included. Where EMR problem list and administrative claims data were in agreement for or against AMI diagnosis they were highly accurate. Where administrative claims data, but not EMR problem list, reported AMI the most common explanation was true AMI with missing EMR problem list diagnoses (60%). Less common reasons for discordance in this category include: (1) administrative coding error (20%), (2) computer algorithm error (8%), (3) patient death before EMR problem list created (4%), (4) EMR problem list not used (4%) and (5) AMI diagnosis was removed from EMR problem list (4%). Where EMR problem list, but not administrative claims data, reported AMI the most common explanation was no AMI with historical diagnosis of AMI from a previous admission (60%). Less common reasons for discordance in this category include: (1) AMI present but not the principal diagnosis (32%), (2) administrative coding error (4%) and (3) erroneous EMR problem list entry (4%). Conclusion: Compared to administrative and chart review diagnoses, we found that using the EMR problem list to identify patient admissions with a principal diagnosis of AMI will overlook a subset of patients primarily due to inadequate clinical documentation. Additionally, the EMR problem list does not discriminate the admission principal diagnosis from the secondary diagnoses.

scholarly journals PPX-TEC API APP: A unique approach to sending and receiving health and insurance data

2019 ◽  
Vol 4 (2) ◽  
Keyword(s):  
Medical Record ◽  
Healthcare Systems ◽  
Veterans Affairs ◽  
Patient Record ◽  
Record System ◽  
Medical Record System ◽  
Unique Approach ◽  
Computerized Patient Record ◽  
Insurance Data ◽  
The U.S

In 1971, the U.S. Dept. of Veterans Affairs (VA) became one of the first large healthcare systems to fully implement a computerized patient record system. Shortly thereafter, in 1972, Regenstrief developed the Regenstrief Medical Record System (RMRS), a historically important EMR. The purpose of this early EMR was described in a quote that is still applicable today:

scholarly journals Attitudes toward inter-hospital electronic patient record exchange: discrepancies among physicians, medical record staff, and patients

2015 ◽  
Vol 15 (1) ◽  
Author(s):  
Jong-Yi Wang ◽  
Hsiao-Yun Ho ◽  
Jen-De Chen ◽  
Sinkuo Chai ◽  
Chih-Jaan Tai ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Patient Record ◽  
Patient Record

scholarly journals Factors Influencing Problem List Use in Electronic Health Records—Application of the Unified Theory of Acceptance and Use of Technology

2020 ◽  
Vol 11 (03) ◽  
pp. 415-426
Author(s):  
Eva S. Klappe ◽  
Nicolette F. de Keizer ◽  
Ronald Cornet
Keyword(s):  
Peer To Peer ◽  
Data Reuse ◽  
Care Process ◽  
Free Text ◽  
Problem List ◽  
Unified Theory ◽  
Peer Training ◽  
Large Variability ◽  
Electronic Health ◽  
Problem Lists

Abstract Background Problem-oriented electronic health record (EHR) systems can help physicians to track a patient's status and progress, and organize clinical documentation, which could help improving quality of clinical data and enable data reuse. The problem list is central in a problem-oriented medical record. However, current problem lists remain incomplete because of the lack of end-user training and inaccurate content of underlying terminologies. This leads to modifications of diagnosis code descriptions and use of free-text notes, limiting reuse of data. Objectives We aimed to investigate factors that influence acceptance and actual use of the problem list, and used these to propose recommendations, to increase the value of problem lists for (re)use. Methods Semistructured interviews were conducted with physicians, heads of medical departments, and data quality experts, who were invited through snowball sampling. The interviews were transcribed and coded. Comments were fitted in constructs of the validated framework unified theory of acceptance user technology (UTAUT), and were discussed in terms of facilitators and barriers. Results In total, 24 interviews were conducted. We found large variability in attitudes toward problem list use. Barriers included uncertainty about the responsibility for maintaining the problem list and little perceived benefits. Facilitators included the (re)design of policies, improved (peer-to-peer) training to increase motivation, and positive peer feedback and monitoring. Motivation is best increased through sharing benefits relevant in the care process, such as providing overview, timely generation of discharge or referral letters, and reuse of data. Furthermore, content of the underlying terminology should be improved and the problem list should be better presented in the EHR system. Conclusion To let physicians accept and use the problem list, policies and guidelines should be redesigned, and prioritized by supervising staff. Additionally, peer-to-peer training on the benefits of using the problem list is needed.

scholarly journals One list to rule them all and many semantics to bind them: Building a shared, scalable and sustainable source for the problem oriented medical record (Preprint)

2021 ◽  
Author(s):  
Christophe Gaudet-Blavignac ◽  
Andrea Rudaz ◽  
Christian Lovis
Keyword(s):  
Medical Record ◽  
Public Hospitals ◽  
Machine Learning Techniques ◽  
Free Text ◽  
Problem List ◽  
Snomed Ct ◽  
University Hospitals ◽  
Additional Information ◽  
Work Breaks ◽  
The Impact

BACKGROUND Since the creation of the Problem Oriented Medical Record, the building of problem lists has been the focus of many researches. To this day, this issue is not well resolved, and building an appropriate contextualized problem list is still a challenge. OBJECTIVE This paper presents the process of building a shared multi-purpose common problem list at the University Hospitals of Geneva, a consortium of all public hospitals and 30 outpatient clinics of the state of Geneva. This list aims at bridging the gap between clinicians’ language expressed in free text and secondary usages requiring structured information. METHODS The strategy focuses on the needs of clinicians by building a list of uniquely identified expressions to support their daily activities. In a second stage, these expressions are connected to additional information, building a complex graph of information. A list of 45,946 expressions manually extracted from clinical documents has been manually curated and encoded in multiple semantic dimensions, such as ICD-10, ICPC-2, SNOMED-CT or dimensions dictated by specific usages, such as identifying expressions specific to a domain, a gender, or an intervention. The list has been progressively deployed for clinicians with an iterative process of quality control, maintenance and improvements, including addition of new expressions, or dimensions for specific needs. The problem management of the electronic health record allowed to measure and correct the encoding based on real-world usage. RESULTS The list was deployed in production in January 2017 and was regularly updated and deployed in new divisions of the hospital. In 4 years, 684,102 problems were created using the list. The proportion of free text entries reduced progressively from 37.47% (8,321/22,206) in December 2017 to 18.38% (4,547/24,738) in December 2020. In the last version of the list, over 14 dimensions were mapped to expressions, among them 5 international classifications and 8 other classifications for specific usages. The list became a central axis in the EHR, being used for many different purposes linked to care such as surgical planning or emergency wards, or in research, for various predictions using machine learning techniques. CONCLUSIONS This work breaks with common approaches primarily by focusing on real clinicians’ language when expressing patient’s problems and secondly by mapping whatever is required, including controlled vocabularies to answer specific needs. This approach improves the quality of the expression of patients’ problems, while allowing to build as many structured dimensions as needed to convey semantics according to specific contexts. The method is shown to be scalable, sustainable and efficient at hiding the complexity of semantics or the burden of constraint structured problem list entry for clinicians. Ongoing work is analyzing the impact of this approach at influencing how clinicians express patient’s problems.

scholarly journals Data quality of electronic medical records in Manitoba: do problem lists accurately reflect chronic disease billing diagnoses?

2016 ◽  
Vol 23 (6) ◽  
pp. 1107-1112 ◽  
Author(s):  
Alexander Singer ◽  
Sari Yakubovich ◽  
Andrea L Kroeker ◽  
Brenden Dufault ◽  
Roberto Duarte ◽  
...  
Keyword(s):  
Primary Care ◽  
Data Quality ◽  
Chronic Diseases ◽  
Chronic Obstructive ◽  
Problem List ◽  
Chronic Obstructive Pulmonary Disorder ◽  
Pulmonary Disorder ◽  
Artery Disease ◽  
Problem Lists

Abstract Objective To determine problem list completeness related to chronic diseases in electronic medical records (EMRs) and explore clinic and physician factors influencing completeness. Methods A retrospective analysis of primary care EMR data quality related to seven chronic diseases (hypertension, diabetes, asthma, congestive heart failure, coronary artery disease, hypothyroidism, and chronic obstructive pulmonary disorder) in Manitoba, Canada. We included 119 practices in 18 primary care clinics across urban and rural Manitoba. The main outcome measure was EMR problem list completeness. Completeness was measured by comparing the number of EMR-documented diagnoses to the number of billings associated with each disease. We calculated odds ratios for the effect of clinic patient load and salary type on EMR problem list completeness of the 7 chronic diseases. Results Completeness of EMR problem list for each disease varied widely among clinics. Factors that significantly affected EMR problem list completeness included the primary care provider, the patient load, and the clinic’s funding and organization model (ie, salaried, fee-for-service, or residency training clinics). Average rates of completeness were: hypertension, 72%; diabetes, 80%; hypothyroidism, 63%; asthma, 56%; chronic obstructive pulmonary disorder, 43%; congestive heart failure, 54%; and coronary artery disease, 64%. Conclusion This study demonstrates the high variability but generally low quality of problem lists (health condition records) related to 7 common chronic diseases in EMRs. There are systematic physician- and clinic-level factors associated with low data quality completeness. This information may be useful to support improvement in EMR data quality in primary care.

scholarly journals Integrating third-party telehealth records with the general practice electronic medical record system: a solution.

2017 ◽  
Vol 24 (4) ◽  
pp. 317 ◽  
Author(s):  
Mary Paterson ◽  
Alison McAulay ◽  
Brian McKinstry
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Record System ◽  
Third Party ◽  
Patient Record ◽  
Record System ◽  
System A ◽  
Medical Record System ◽  
General Practices

Background: The implementation of telemonitoring at scale has been less successful than anticipated, often hindered by clinicians’ perceived increase in workload. One important factor has been the lack of integration of patient generated data (PGD) with the electronic medical record (EMR). Clinicians have had problems accessing PGD on telehealth systems especially in patient consultations in primary care.Objective: To design a method to produce a report of PGD that is available to clinicians through their routine EMR system.Method: We modelled a system with a use case approach using Unified Modelling Language to enable us to design a method of producing the required report. Anonymised PGD are downloaded from a third-party telehealth system to National Health Service (NHS) systems and linked to the patient record available in the hospital recording system using the patient NHS ID through an interface accessed by healthcare professionals. The telehealth data are then processed into a report using the patient record. This report summarises the readings in graphical and tabular form with an average calculated and with a recommended follow-up suggested if required. The report is then disseminated to general practitioner practices through routine document distribution pathways.Results: This addition to the telehealth system is viewed positively by clinicians. It has helped to greatly increase the number of general practices using telemonitoring to manage blood pressure in NHS Lothian.

Sign in / Sign up

Export Citation Format

Share Document