scholarly journals A value set for documenting adverse reactions in electronic health records

2017 ◽  
Vol 25 (6) ◽  
pp. 661-669 ◽  
Author(s):  
Foster R Goss ◽  
Kenneth H Lai ◽  
Maxim Topaz ◽  
Warren W Acker ◽  
Leigh Kowalski ◽  
...  
Keyword(s):  
Health Information ◽  
Adverse Reactions ◽  
Medical Center ◽  
Information Modeling ◽  
Hypersensitivity Reactions ◽  
Health Records ◽  
Value Set ◽  
External Resources ◽  
A Value ◽  
Electronic Health

Abstract Objective To develop a comprehensive value set for documenting and encoding adverse reactions in the allergy module of an electronic health record. Materials and Methods We analyzed 2 471 004 adverse reactions stored in Partners Healthcare’s Enterprise-wide Allergy Repository (PEAR) of 2.7 million patients. Using the Medical Text Extraction, Reasoning, and Mapping System, we processed both structured and free-text reaction entries and mapped them to Systematized Nomenclature of Medicine – Clinical Terms. We calculated the frequencies of reaction concepts, including rare, severe, and hypersensitivity reactions. We compared PEAR concepts to a Federal Health Information Modeling and Standards value set and University of Nebraska Medical Center data, and then created an integrated value set. Results We identified 787 reaction concepts in PEAR. Frequently reported reactions included: rash (14.0%), hives (8.2%), gastrointestinal irritation (5.5%), itching (3.2%), and anaphylaxis (2.5%). We identified an additional 320 concepts from Federal Health Information Modeling and Standards and the University of Nebraska Medical Center to resolve gaps due to missing and partial matches when comparing these external resources to PEAR. This yielded 1106 concepts in our final integrated value set. The presence of rare, severe, and hypersensitivity reactions was limited in both external datasets. Hypersensitivity reactions represented roughly 20% of the reactions within our data. Discussion We developed a value set for encoding adverse reactions using a large dataset from one health system, enriched by reactions from 2 large external resources. This integrated value set includes clinically important severe and hypersensitivity reactions. Conclusion This work contributes a value set, harmonized with existing data, to improve the consistency and accuracy of reaction documentation in electronic health records, providing the necessary building blocks for more intelligent clinical decision support for allergies and adverse reactions.

Safe Use of Electronic Health Records and Health Information Technology Systems

2013 ◽  
Vol 9 (4) ◽  
pp. 177-189 ◽  
Author(s):  
Charles R. Denham ◽  
David C. Classen ◽  
Stephen J. Swenson ◽  
Michael J. Henderson ◽  
Thomas Zeltner ◽  
...  
Keyword(s):  
Information Technology ◽  
Electronic Health Records ◽  
Health Information Technology ◽  
Health Information ◽  
Health Records ◽  
Electronic Health ◽  
Technology Systems

scholarly journals The Postencounter Form System: Viewpoint on Efficient Data Collection Within Electronic Health Records (Preprint)

2019 ◽  
Author(s):  
Philip Held ◽  
Randy A Boley ◽  
Walter G Faig ◽  
John A O'Toole ◽  
Imran Desai ◽  
...  
Keyword(s):  
Electronic Health Records ◽  
Medical Center ◽  
Health Records ◽  
Clinical Notes ◽  
The Road ◽  
Clinical Encounters ◽  
Efficient Data ◽  
Data Points ◽  
Electronic Health ◽  
Using Data

UNSTRUCTURED Electronic health records (EHRs) offer opportunities for research and improvements in patient care. However, challenges exist in using data from EHRs due to the volume of information existing within clinical notes, which can be labor intensive and costly to transform into usable data with existing strategies. This case report details the collaborative development and implementation of the postencounter form (PEF) system into the EHR at the Road Home Program at Rush University Medical Center in Chicago, IL to address these concerns with limited burden to clinical workflows. The PEF system proved to be an effective tool with over 98% of all clinical encounters including a completed PEF within 5 months of implementation. In addition, the system has generated over 325,188 unique, readily-accessible data points in under 4 years of use. The PEF system has since been deployed to other settings demonstrating that the system may have broader clinical utility.

Two Important Topics for 2012: Electronic Health Records and mHealth

2012 ◽  
Vol 47 (1) ◽  
pp. 62-63 ◽  
Author(s):  
I. Fox Brent ◽  
G. Felkey Bill
Keyword(s):  
Information Technology ◽  
Electronic Health Records ◽  
Health Information Technology ◽  
Health Information ◽  
Health It ◽  
Time And Space ◽  
Health Records ◽  
Electronic Health

As the new year begins, we like to reflect on where health information technology (IT) has been and where it is going. We are not fond of rehashing the minutia regarding every event that occurred in the health IT domain, so we will not spend our time and space presenting an exhaustive review. We will, however, touch on the continuing efforts surrounding electronic health records (EHRs). We will also focus forward in discussing an emerging area that we are closely following.

scholarly journals Findings from the 2017 Yearbook Section on Health Information Management

2017 ◽  
Vol 26 (01) ◽  
pp. 78-83
Author(s):  
M. Bloomrosen ◽  
E. S. Berner
Keyword(s):  
Health Information ◽  
Information Management ◽  
Information Exchange ◽  
Healthcare Delivery ◽  
Health Information Management ◽  
Bibliographic Databases ◽  
Future Research ◽  
Privacy And Security ◽  
Health Records ◽  
Electronic Health

Summary Objectives: To summarize the recent literature and research and present a selection of the best papers published in 2016 in the field of Health Information Management (HIM). Methods: A systematic review of the literature for the IMIA Yearbook HIM section was performed by the two section editors with the help of a medical librarian. We searched bibliographic databases for HIM-related papers were searched using both MeSH headings and key words in titles and abstracts. A shortlist of candidate best papers was first selected by section editors before being peer-reviewed by independent external reviewers. Results: The five papers selected as ‘Best Papers’ illustrate a variety of themes, include authors from a variety of countries, and were published in some of the best journals in the field. The themes of the five best papers include health information exchange, personal health records, patient engagement, data quality, and e-quality measures. Conclusions: The discipline of Health Information Management is increasingly becoming allied with the field of Biomedical Informatics in that both disciplines have interests in common. Traditional HIM areas of expertise (in the pre-electronic health record world), such as coding and privacy and security of health information, are necessary for the electronic exchange and secondary use of health information. With the changes in healthcare delivery brought by the use of electronic health records, addressing issues of information governance is essential. This synopsis discusses these key issues at the intersection of HIM and informatics, examines the potential challenges, and points the way for best practices, future research, and public policy considerations and directions.

Abstract 2573: Cancer diagnoses and patient use of electronic health records: results from the health information national trends survey

2016 ◽  
Author(s):  
Alexandra J. Greenberg ◽  
Angela Falisi ◽  
Lila J. Finney Rutten ◽  
Wen-Ying Sylvia Chou ◽  
Richard P. Moser ◽  
...  
Keyword(s):  
Electronic Health Records ◽  
Health Information ◽  
Health Records ◽  
Electronic Health ◽  
National Trends ◽  
Patient Use
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