A microcomputer record system for diabetic patients

A computerised medical records system for diabetic patients has been developed on a Vector Graphics MZ microcomputer using programs written in UCSD-Pascal. The system allows addition or deletion of patient records, alteration of records, alphabetical listing of recorded patients' names, and printing of individual records in a concise format. The amount of information capable of being stored in each record makes the easy to use system a useful device in the clinical management of diabetic patients.     

Live sequence charts to model medical information

ABSTRACT: BACKGROUND: Medical records accumulate data concerning patient health and the natural history of disease progression. However, methods to mine information systematically in a form other than an electronic health record are not yet available. The purpose of this study was to develop an object modeling technique as a first step towards a formal database of medical records. METHOD: Live Sequence Charts (LSC) were used to formalize the narrative text obtained during a patient interview. LSCs utilize a visual scenario-based programming language to build object models. LSC extends the classical language of UML message sequence charts (MSC), predominantly through addition of modalities and providing executable semantics. Interobject scenarios were defined to specify natural history event interactions and different scenarios in the narrative text. Result A simulated medical record was specified into LSC formalism by translating the text into an object model that comprised a set of entities and events. The entities described the participating components (i.e., doctor, patient and record) and the events described the interactions between elements. A conceptual model is presented to illustrate the approach. An object model was generated from data extracted from an actual new patient interview, where the individual was eventually diagnosed as suffering from Chronic Fatigue Syndrome (CFS). This yielded a preliminary formal designated vocabulary for CFS development that provided a basis for future formalism of these records. CONCLUSIONS: Translation of medical records into object models created the basis for a formal database of the patient narrative that temporally depicts the events preceding disease, the diagnosis and treatment approach. The LSCs object model of the medical narrative provided an intuitive, visual representation of the natural history of the patient's disease.     

Informal complaints procedure in general practice: first year's experience.

OBJECTIVE--To evaluate the first year''s experience of an informal patient complaints system that encourages extensive patient participation. DESIGN--Audit of an informal complaints procedure. SETTING--The Marylebone Health Centre, London. SUBJECTS--39 complaints received over the audit period. MAIN OUTCOME MEASURES--Types of complaints (administrative, about doctors or medical care or both, staff about patients, mixed, other) and resolution of complaints (how complaints were dealt with and their resolution). RESULTS--37 of the 39 complaints were resolved within two weeks. Two complaints sent direct to the family health services authority were resolved (with patients'' agreement) by the informal complaints procedure. CONCLUSIONS--The informal complaints procedure was more cost effective than the family health services authority system and was comparatively straightforward to implement within the practice without major organisational restructuring. The two way process of the procedure ensured patients received a quick response to complaints and helped morale of health centre staff.     

From Hippocrates to facsimile: Protecting patient confidentiality is more difficult and more important than ever before

Although patient confidentiality has been a fundamental ethical principle since the Hippocratic Oath, it is under increasing threat. The main area of confidentiality is patient records. Physicians must be able to store and dispose of medical records securely. Patients should be asked whether some information should be kept out of the record or withheld if information is released. Patient identity should be kept secret during peer review of medical records. Provincial legislation outlines circumstances in which confidential information must be divulged. Because of the "team approach" to care, hospital records may be seen by many health care and administrative personnel. All hospital workers must respect confidentiality, especially when giving out information about patients by telephone or to the media. Research based on medical-record review also creates challenges for confidentiality. Electronic technology and communications are potential major sources of breaches of confidentiality. Computer records must be carefully protected from casual browsing or from unauthorized access. Fax machines and cordless and cellular telephones can allow unauthorized people to see or overhear confidential information. Confidentiality is also a concern in clinical settings, including physicians'' offices and hospitals. Conversations among hospital personnel in elevators or public cafeterias can result in breaches of confidentiality. Patient confidentiality is a right that must be safeguarded by all health care personnel.     

电子病历系统在医院信息管理系统中应用初探

电子病历系统是通过计算机等电子设备为载体,对医院患者的诊疗活动进行数字化记录的软件。电子病历中详细记录了医嘱、病程、过敏史、影像检查结果、出院记录等多项医疗数据。电子病历完整、系统、科学地记录了患者身体健康情况以及历次就诊记录,通过一个维度将患者内部不同层次的信息有机的联系在一起。与传统的纸张病历相比,电子病历可以迅速实现不同时间、不同医院医疗信息的高效整合以及信息共享,为临床诊疗提供大量科学准确的信息,大大提高医院的服务效率。本文通过电子病历系统在医院信息管理系统中的应用情况进行简要分析,以期提高电子病历系统在临床中解决实际医疗问题的能力。     

Cost effectiveness of magnetic resonance imaging in the neurosciences.

OBJECTIVES--To measure, in a service setting, the effect of magnetic resonance imaging on diagnosis, diagnostic certainty, and patient management in the neurosciences; to measure the cost per patient scanned; to estimate the marginal cost of imaging and compare this with its diagnostic impact; to measure changes in patients'' quality of life; and to record the diagnostic pathway leading to magnetic resonance imaging. DESIGN--Controlled observational study using questionnaires on diagnosis and patient management before and after imaging. Detailed costing study. Quality of life questionnaires at the time of imaging and six months later. Diagnostic pathways extracted from medical records for a representative sample. SETTING--Regional superconducting 1.5 T magnetic resonance service. SUBJECTS--782 consecutive neuroscience patients referred by consultants for magnetic resonance imaging during June 1988-9; diagnostic pathways recorded for 158 cases. MAIN OUTCOME MEASURES--Costs of magnetic resonance imaging and preliminary investigations; changes in planned management and resulting savings; changes in principal diagnosis and diagnostic certainty; changes in patients'' quality of life. RESULTS--Average cost of magnetic resonance imaging was estimated at 206.20/patient pounds (throughput 2250 patients/year, 1989-90 prices including contrast and upgrading). Before magnetic resonance imaging diagnostic procedures cost 164.40/patient pounds (including inpatient stays). Management changed after imaging in 208 (27%) cases; saving an estimated 80.90/patient pounds. Confidence in planned management increased in a further 226 (29%) referrals. Consultants'' principal diagnosis changed in 159 of 782 (20%) referrals; marginal cost per diagnostic change was 626 pounds. Confidence in diagnosis increased in 236 (30%) referrals. No improvement in patients'' quality of life at six month assessment. CONCLUSIONS--Any improvement in diagnosis with magnetic resonance imaging is achieved at a higher cost. Techniques for monitoring the cost effectiveness of this technology need to be developed.     

Effective audit: reporting to the National Confidential Enquiry into Perioperative Deaths.

OBJECTIVE--To investigate the effectiveness of computer based and manual district and unit information systems for identifying hospital deaths eligible for reporting to the National Confidential Enquiry into Perioperative Deaths (NCEPOD). DESIGN--Prospective six to 10 week study of hospital (death register, immediate coding of medical records) and district information systems followed by six month assessment after modification to entry of data. SETTING--Acute units within Lewisham and North Southwark Health District. PATIENTS--All 290 patients dying in hospital during the six weeks, for whom the medical records were obtainable in 231. MAIN OUTCOME MEASURES--Sensitivity and specificity of the information systems in ascertaining eligible surgical deaths (patients dying in hospital who had during 30 days previously had a surgical procedure while under the care of a consultant in a surgical specialty) tested against validated list of screened medical records. RESULTS--Of 231 medical records, 30 (12 from Lewisham, 18 from North Southwark) met the national inquiry''s criteria. The computer based systems of both units detected less than 60% of eligible deaths (sensitivity 53%, specificity 83%); the death register detected about 60% (sensitivity 61%, specificity 89%); manual systems detected all eligible deaths. Subsequent modification to ensure immediate coding of records into the computerised systems during follow up failed to show any improvement. IMPLICATIONS--Routine hospital information systems may miss up to half the deaths eligible for NCEPOD.     

Fair shares in health care? Ethnic and socioeconomic influences on recording of preventive care in selected inner London general practices. Healthy Eastenders Project.

OBJECTIVE--To describe the association of ethnic and socioeconomic status with recording of preventive care information by selected general practitioners. DESIGN--Random selection of people aged 20-64 registered with 43 general practitioners. Ethnic and social characteristics of stratified samples were determined at interview in the subject''s home. Recording of preventive information was ascertained from general practitioners'' medical records. SETTING--Inner London borough of Tower Hamlets. SUBJECTS--505 ut of 739 people confirmed as residents at their home address (190 white, 86 black, 112 Bangladeshi, 105 Chinese or Vietnamese, 12 other). MAIN OUTCOME MEASURES--Socioeconomic characteristics, consultation with general practitioner, and recorded preventive activities for ethnic groups. RESULTS--Minority ethnic groups were considerably more disadvantaged than white people and five times more likely to be overcrowded (31% v 6%), three times less likely to own their own home(11% v 37%), twice as likely to be in social classes IV and V (54% v 28%) and less likely to be employed (34% v 63%). There were no significant differences between white, black, Bangladeshi, and Chinese or Vietnamese subjects in recording smoking, blood pressure, alcohol consumption, weight, and height in the general practitioners'' medical records. White women were more likely to have a record of mammography (46% v 20%; P=0.03) and of cervical smears than women in minority ethnic groups. CONCLUSION--Despite major socioeconomic inequity, equitable recording of preventive activity for the major causes of death for white, black and Bangladeshi populations is possible. Chinese and Vietnamese people had lower levels of recording and consultation. Mammography and, to a lesser extent, cervical cytology are inequitably recorded and require additional support at practice level.     

Evaluation of a decision support system in a medical environment

This paper describes the impact of a decision support system on the quality of recorded diagnoses and the completeness of medical records. The assumption is that for quality assessment purposes enough data have to be recorded in an electronic medical record so that diagnostic decisions can be justified. The hypotheses were tested that active decision support will lead to better quality recorded diagnoses and more complete medical records. Three groups of ten GPs were presented with 10 cases each. The GPs had to enter the data about these cases in a GP information system. One group of GPs was not supported. The second group was presented with the ICHPPC-II-Defined criteria that had to be fulfilled when a diagnosis was entered. In a third group, the GPs were asked those data that were needed to justify an entered diagnosis (active support). It could be shown that the last group of GPs entered better quality diagnoses than the other two groups. These latter groups also entered so little data that most of their diagnoses could not be justified. It is concluded from the study that only active decision support will lead to better diagnoses and a more complete medical record that can be used for quality assessment.     

某二级医院住院病历中不良事件风险评估的应用与研究

目的:通过病历中发生的不良事件及其风险度来评价病历质量,目的为加强病历环节和细节的质控,减少或杜绝病历中不良事件的发生,提高病历书写质量,保证医疗安全,减少医疗纠纷。方法:随机抽查2007-2010年某二级医院住院病历4837份,对其进行不良事件风险评估,对病历的终末质量和环节质量进行综合评价分析,找出影响医疗质量的相关联因素。结果:通过对某二级医院2007-2010年随机抽查的终末病历和病房中运行病历的不良事件风险评估,数据经过统计学处理后P值<0.01,说明总的病历中不良事件发生率年度间逐年减少,有极为显著的差别,证明此种病历评价方法切实可行。结论:病历中不良事件风险评估,是减少病历中不良事件发生的有效办法,可以消除病历书写中存在的医患矛盾和医疗纠纷隐患。     

Electronic health records: the European scene.

Caring for patients'' health problems relies increasingly on sharing information between clinical departments and disciplines and with managers. The medical record of the future will need to provide a flexible and shareable framework for recording and analysing the consultation process. The advanced informatics in medicine (AIM) programme seeks to encourage research and development in telemedicine in areas that are beyond the scope of any one country. It includes many European projects attempting to define the best storage and transmission formats for such diverse data types as laboratory results, biosignals, x ray images, and photographs, and in clinical specialties varying from intensive care to medicine for elderly people. One example, the good European health record project, is developing a model architecture for computerised health records across Europe that is capable of operating on a wide variety of computer hardwares and will also be able to communicate with many different information systems. The ultimate European health record will be comprehensive and medicolegally acceptable across clinical domains, hold all data types, and be automatically translated between languages.     

Active approach to recognising asthma in general practice.

The general practice medical records of 214 children born in 1977 were scrutinised for a diagnosis of asthma. In 18 (8%) of these a diagnosis of asthma had been entered. Using a scoring system based on the medical record a further group of children who were thought likely to have undiagnosed asthma was exercise tested. Twelve children (6%) had demonstrable exercise induced asthma. In addition, seven children (3%) had both frequent respiratory symptoms and borderline exercise test results, indicating that they too had clinically important airways obstruction. As expected, histories of atopic eczema, nocturnal cough, persistent cough (more than one week), and wheezing appeared often in the medical records of the children with asthma. In combinations these diagnostic clues were more than 50% predictive of asthma. A more active approach in general practice to the diagnosis of asthma in children is both necessary and possible.     

Quality of data in the Manchester orthopaedic database.

OBJECTIVE--To determine the completeness and accuracy of data in a computerised clinical information system (Manchester orthopaedic database) in comparison with the data available through the Hospital Activity Analysis. DESIGN--Retrospective review of case notes, computer data, and Hospital Activity Analysis data. SETTING--Orthopaedic unit in a district general hospital in Manchester. SUBJECTS--200 random patient records distributed through the period of use of the computer system (1 October 1988 to 31 March 1990) and 121 records for random admissions between 1 April 1989 and 31 March 1990, 71 of which were included in the previous sample. MAIN OUTCOME MEASURES--Conformity of the computer record key words and Hospital Activity Analysis codes to an ideal key word record and ideal code record drawn up by one investigator from the clinical notes; overall quality (completeness times accuracy). RESULTS--Overall completeness of the data in the orthopaedic database was 62% and the accuracy was 96%. Completeness improved after feedback to doctors on the use of key words in regular audit meetings. Completeness was higher in inpatient than outpatient records (69.9% v 53.7%, p less than 0.001) and when a new key word was required compared with missing and incorrect key words (both p less than 0.001). Completeness was lower when the key word was required of a senior registrar (p less than 0.05). Accuracy was not significantly different. The completeness of Hospital Activity Analysis data was 90.5% and accuracy 69.5%. Thus the overall data quality was similar in both systems. CONCLUSIONS--Even in a system designed for simple and efficient data capture, compliance by users was poor. Accuracy was high, suggesting that users understood the principles of data entry. Completeness of data capture can be improved by providing feedback to users on use of the system and performance. Improvements in future versions of the software should improve performance.     

Intra-Rater and Inter-Rater Reliability of a Medical Record Abstraction Study on Transition of Care after Childhood Cancer

BackgroundThe abstraction of data from medical records is a widespread practice in epidemiological research. However, studies using this means of data collection rarely report reliability. Within the Transition after Childhood Cancer Study (TaCC) which is based on a medical record abstraction, we conducted a second independent abstraction of data with the aim to assess a) intra-rater reliability of one rater at two time points; b) the possible learning effects between these two time points compared to a gold-standard; and c) inter-rater reliability.MethodWithin the TaCC study we conducted a systematic medical record abstraction in the 9 Swiss clinics with pediatric oncology wards. In a second phase we selected a subsample of medical records in 3 clinics to conduct a second independent abstraction. We then assessed intra-rater reliability at two time points, the learning effect over time (comparing each rater at two time-points with a gold-standard) and the inter-rater reliability of a selected number of variables. We calculated percentage agreement and Cohen’s kappa.FindingsFor the assessment of the intra-rater reliability we included 154 records (80 for rater 1; 74 for rater 2). For the inter-rater reliability we could include 70 records. Intra-rater reliability was substantial to excellent (Cohen’s kappa 0-6-0.8) with an observed percentage agreement of 75%-95%. In all variables learning effects were observed. Inter-rater reliability was substantial to excellent (Cohen’s kappa 0.70-0.83) with high agreement ranging from 86% to 100%.ConclusionsOur study showed that data abstracted from medical records are reliable. Investigating intra-rater and inter-rater reliability can give confidence to draw conclusions from the abstracted data and increase data quality by minimizing systematic errors.     

Diagnosis, treatment, and outcome of eastern box turtles (Terrapene carolina carolina) presented to a wildlife clinic in Tennessee, USA, 1995-2007

We performed a retrospective review of medical records for 574 eastern box turtles (Terrapene carolina carolina) that presented to the University of Tennessee College of Veterinary Medicine (UTCVM) wildlife clinic between 1995 and 2007. These cases were reviewed to document and investigate the presenting complaints, as identified by a good Samaritan, final diagnoses, treatment modalities, days in hospital, and final disposition. Presenting complaints were consistent with the final diagnoses in 81% of cases. Trauma was both the most common presentation and final diagnosis. Associations between final diagnosis and either environmental temperature or precipitation were not significant (P>0.05). However, precipitation had a statistically significant positive association (P<0.05) with aural abscessation. Approximately 5% (28/574) of the box turtles were evaluated for packed cell volume total protein and white blood cell count. No differences were observed between sick and healthy animals for any of these variables. Multiple treatment modalities were used in these cases and were often used in combination, rather than as individual therapies. The number of days spent in the hospital ranged from 0 to 66 days, with a median of 2 days. The wildlife clinic of UTCVM should continue to evaluate the health status of eastern box turtles. Our findings indicate that the high caseload, as well as case variety of eastern box turtles in eastern Tennessee, suggests potential use as a biomonitor for this species.     

Socio-medical condition and oral functional status in an older institutionalised population

Objectives: To investigate the association between the general medical condition, the socio-economic status, and some factors related to the functional status of the stomatognathic system. Design: A survey in an elderly population. Subjects: 257 older adults, with a mean age of 83.7 years. Setting: Residential homes for the elderly. Intervention: Examination of the medical records on the overall health and the drugs consumed, a structured interview on the socio-economic status, the complaints for xerostomia, the subjective chewing difficulties, and a clinical evaluation of the number of natural teeth and the number of posterior occluding pairs of teeth contacts (premolars and molars). Results: Multiple pathology and polypharmacy were recorded. 25% of the residents had no occluding posterior tooth contact (natural or prosthetic) and 62% were edentulous. 43% of the residents reported complaints for xerostomia, and 46% for chewing difficulties when eating specific food types. Xerostomic feelings and chewing problems were not related to age. Chewing difficulties were not related to the number of natural teeth, but to the number of posterior occluding teeth contacts, natural or prosthetic (less than two). From all medical conditions examined, only the psychiatric disorders were significantly related to dental status (p<0.05). Moreover, the number of remaining natural teeth was related to socio-economic status, while the number of posterior occluding teeth contacts was also inversely related to the duration of institutionalisation (p<0.05). Conclusions: Psychiatric disorders, low socio-economic status and increased duration of institutionalisation were most closely related to poor dental status. The presence of more than two posterior occluding teeth contacts, natural or prosthetic, benefit the very old patient in terms of reduced subjective chewing difficulty. A formal oral care delivery system for the institutionalised elderly, and particularly for those suffering from psychiatric disorders, is imperative.     

Conventional respiratory cytology versus fine needle aspiration cytology in the diagnosis of lung cancer

The results of 184 fine needle aspiration (FNA) cytologic examinations were compared with the findings of "conventional" respiratory cytology (on sputums, bronchial brushings and bronchial washings) and histology (on biopsy and autopsy samples) and with the medical records. Positive cytologic results were obtained in 6 (10%) of 60 sputums, 17 (21%) of 80 brushings, 16 (19%) of 84 washings and 82 (44%) of 184 aspirates. These positive results were confirmed by biopsy for 6 of 6 sputums, 16 of 17 brushings and 15 of 16 washings. Among the 82 patients with a positive FNA cytology, malignancy was confirmed by lung biopsy in 39 and by autopsy in 2; the cytologic diagnosis was supported by clinical and radiographic findings in all but 1 of the remaining 41 patients. Using transbronchial lung biopsy, autopsy and medical records as final standards, the positive predictive values were 100% for sputum, 94.1% for brushings, 93.0% for washings and 98.6% for FNA samples. The high positive predictive values of FNA and the other cytologic procedures indicate that these diagnostic modalities provide simple, rapid and reliable methods for the diagnosis of lung cancer.     

Ascertainment of a mid-western US female adolescent twin cohort for alcohol studies: assessment of sample representativeness using birth record data.

Female twin pairs were identified from birth records, and their families invited to participate in a prospective study of the determinants of alcohol problems in women. We investigated sampling biases arising because of failure to locate families, or non-cooperation of families. Out of 2644 families with a live-born pair (born between July 1975 and December 1986) who survived beyond infancy, contact was established and a brief screening interview completed with 90% (N = 2380). Fewer than 6% of located families declined to participate in the initial screening interview. Predictors of failure to locate a family or to obtain a screening interview were identified from information recorded in birth records, and from neighborhood characteristics identified from 1990 US Census block group data for the family residence when the twins were born. African-American families were under-represented in the final sample, but this effect was barely significant when other variables were controlled for. Under-represented were families where the mother was 19 or younger at the birth of the twins, where the mother herself was born out-of-state, or where information about biological father was not reported in the birth record. Non-participating families on average came from neighborhoods with a higher proportion of residents living in poverty, and with a higher proportion of African-American residents. Sampling biases were however small. The unusual cooperativeness in research of families with twins persists.