The Application of Computer-Based Medical-Record Systems in Ambulatory Practice

1989 ◽  
pp. 85-99 ◽  
Author(s):  
G. Octo Barnett
Keyword(s):  
Medical Record ◽  
Computer Based ◽  
Ambulatory Practice

Comparison of Prescription and Medical Records in Reflecting Patient Antihypertensive Drug Therapy

1994 ◽  
Vol 28 (1) ◽  
pp. 99-104 ◽  
Author(s):  
Dale B. Christensen ◽  
Barbara Williams ◽  
Harold I. Goldberg ◽  
Diane P. Martin ◽  
Ruth Engelberg ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Health Maintenance Organizations ◽  
Antihypertensive Drug Therapy ◽  
Antihypertensive Medications ◽  
Pharmacy Records ◽  
Health Maintenance ◽  
Computer Based ◽  
High Level ◽  
Level Of Agreement

OBJECTIVE: To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications. SETTING: Three clinics affiliated with two staff model health maintenance organizations (HMOs). PARTICIPANTS: Randomly selected HMO enrollees (n=982) with diagnosed hypertension. METHODS: Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use. RESULTS: There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5–8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records. CONCLUSIONS: In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

A computer-based, communication-oriented medical record

1999 ◽  
Vol 1 (3/4) ◽  
pp. 288
Author(s):  
H.J. Tange ◽  
V.A.B. Dreessen ◽  
H.H.L.M. Donkers ◽  
A. Hasman
Keyword(s):  
Medical Record ◽  
Computer Based

The PEN & PAD Medical Record Model: Development of a Nursing Record for Hospital-based Care of the Elderly

1994 ◽  
Vol 33 (05) ◽  
pp. 464-472 ◽  
Author(s):  
N. Hardiker ◽  
J. Kirby ◽  
R. Tallis ◽  
M. Gonsalkarale ◽  
H. A. Heathfield
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
General Practitioners ◽  
Model Development ◽  
The Elderly ◽  
Nursing Profession ◽  
Record System ◽  
Professional Background ◽  
Nursing Record ◽  
Computer Based

Abstract:The PEN & PAD Medical Record model describes a framework for an information model, designed to meet the requirements of an electronic medical record. This model has been successfully tested in a computer-based record system for General Practitioners as part of the PEN & PAD (GP) Project.Experiences of using the model for developing computer-based nursing records are reported. Results show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient’s care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work has highlighted the need for nurses to clarify and make explicit their uses of information, and also provided them with some tools to assist in this task.

scholarly journals Computer-Based Stratified Primary Care for Musculoskeletal Consultations Compared With Usual Care: Study Protocol for the STarT MSK Cluster Randomized Controlled Trial (Preprint)

2020 ◽  
Author(s):  
Jonathan Hill ◽  
Stefannie Garvin ◽  
Ying Chen ◽  
Vincent Cooper ◽  
Simon Wathall ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Randomized Controlled Trial ◽  
Medical Record ◽  
Controlled Trial ◽  
Randomized Controlled ◽  
Stratified Care ◽  
Computer Based ◽  
General Practices ◽  
Cluster Randomized

BACKGROUND Musculoskeletal (MSK) pain is a major cause of pain and disability. We previously developed a prognostic tool (Start Back Tool) with demonstrated effectiveness in guiding primary care low back pain management by supporting decision making using matched treatments. A logical next step is to determine whether prognostic stratified care has benefits for a broader range of common MSK pain presentations. OBJECTIVE This study seeks to determine, in patients with 1 of the 5 most common MSK presentations (back, neck, knee, shoulder, and multisite pain), whether stratified care involving the use of the Keele Start MSK Tool to allocate individuals into low-, medium-, and high-risk subgroups, and matching these subgroups to recommended matched clinical management options, is clinical and cost-effective compared with usual nonstratified primary care. METHODS This is a pragmatic, two-arm parallel (stratified vs nonstratified care), cluster randomized controlled trial, with a health economic analysis and mixed methods process evaluation. The setting is UK primary care, involving 24 average-sized general practices randomized (stratified by practice size) in a 1:1 ratio (12 per arm) with blinding of trial statistician and outcome data collectors. Randomization units are general practices, and units of observation are adult MSK consulters without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records are tagged and individuals invited using a general practitioner (GP) point-of-consultation electronic medical record (EMR) template. The intervention is supported by an EMR template (computer-based) housing the Keele Start MSK Tool (to stratify into prognostic subgroups) and the recommended matched treatment options. The primary outcome using intention-to-treat analysis is pain intensity, measured monthly over 6 months. Secondary outcomes include physical function and quality of life, and an anonymized EMR audit to capture clinician decision making. The economic evaluation is focused on the estimation of incremental quality-adjusted life years and MSK pain–related health care costs. The process evaluation is exploring a range of potential factors influencing the intervention and understanding how it is perceived by patients and clinicians, with quantitative analyses focusing on a priori hypothesized intervention targets and qualitative approaches using focus groups and interviews. The target sample size is 1200 patients from 24 general practices, with >5000 MSK consultations available for anonymized medical record data comparisons. RESULTS Trial recruitment commenced on May 18, 2018, and ended on July 15, 2019, after a 14-month recruitment period in 24 GP practices. Follow-up and interview data collection was completed in February 2020. CONCLUSIONS This trial is the first attempt, as far as we know, at testing a prognostic stratified care approach for primary care patients with MSK pain. The results of this trial should be available by the summer of 2020. CLINICALTRIAL ISRCTN Registry ISRCTN15366334; http://www.isrctn.com/ISRCTN15366334. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/17939

A clinician's approach to computer-based medical record systems

1969 ◽  
Vol 1 (4) ◽  
pp. 387-403 ◽  
Author(s):  
J. Anderson ◽  
F. Woodroffe
Keyword(s):  
Medical Record ◽  
Computer Based

scholarly journals Development and validation of a computer-based algorithm to identify foreign-born patients with HIV infection from the electronic medical record

2014 ◽  
Vol 05 (02) ◽  
pp. 557-570 ◽  
Author(s):  
V. Triant ◽  
E. Losina ◽  
K. Keefe ◽  
K. Freedberg ◽  
S. Regan ◽  
...  
Keyword(s):  
Hiv Infection ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Outcomes Research ◽  
Chart Review ◽  
Place Of Birth ◽  
Foreign Born ◽  
Computer Based ◽  
Stage 1 ◽  
Development And Validation

SummaryObjective: To develop and validate an efficient and accurate method to identify foreign-born patients from a large patient data registry in order to facilitate population-based health outcomes research.Methods: We developed a three-stage algorithm for classifying foreign-born status in HIV-infected patients receiving care in a large US healthcare system (January 1, 2001-March 31, 2012) (n = 9,114). In stage 1, we classified those coded as non-English language speaking as foreign-born. In stage 2, we searched free text electronic medical record (EMR) notes of remaining patients for keywords associated with place of birth and language spoken. Patients without keywords were classified as US-born. In stage 3, we retrieved and reviewed a 50-character text window around the keyword (i.e. token) for the remaining patients. To validate the algorithm, we performed a chart review and asked all HIV physicians (n = 37) to classify their patients (n = 957).We calculated algorithm sensitivity and specificity.Results: We excluded 160/957 because physicians indicated the patient was not HIV-infected (n = 54), “not my patient” (n = 103), or had unknown place of birth (n = 3), leaving 797 for analysis. In stage 1, providers agreed that 71/95 foreign language speakers were foreign-born. Most disagreements (23/24) involved patients born in Puerto Rico. In stage 2, 49/50 patients without keywords were classified as US-born by chart review. In stage 3, token review correctly classified 55/60 patients (92%), with 93% (CI: 84.4, 100%) sensitivity and 90% (CI: 74.3, 100%) specificity compared with full chart review. After application of the three-stage algorithm, 2,102/9,114 (23%) patients were classified as foreign-born. When compared against physician response, estimated sensitivity of the algorithm was 94% (CI: 90.9, 97.2%) and specificity 92% (CI: 89.7, 94.1%), with 92% correctly classified.Conclusion: A computer-based algorithm classified foreign-born status in a large HIV-infected cohort efficiently and accurately. This approach can be used to improve EMR-based outcomes research.Citation: Levison J, Triant V, Losina E, Keefe K, Freedberg K, Regan S. Development and validation of a computer-based algorithm to identify foreign-born patients with HIV infection from the electronic medical record. Appl Clin Inf 2014; 5: 557–570 http://dx.doi.org/10.4338/ACI-02-RA-0013

Sign in / Sign up

Export Citation Format

Share Document