Documentation of Child Maltreatment in Electronic Health Records

2017 ◽  
Vol 57 (9) ◽  
pp. 1041-1052 ◽  
Author(s):  
Canan Karatekin ◽  
Brandon Almy ◽  
Susan Marshall Mason ◽  
Iris Borowsky ◽  
Andrew Barnes
Keyword(s):  
Child Maltreatment ◽  
Electronic Health Records ◽  
International Classification Of Diseases ◽  
International Classification ◽  
Self Report ◽  
Protective Services ◽  
Health Records ◽  
Classification Of Diseases ◽  
Electronic Health

International Classification of Diseases codes for child maltreatment can aid surveillance and research, but the extent to which they are used is not well established. We documented prevalence of the use of maltreatment-related codes, examined demographic characteristics of youth assigned these codes, and compared results with previous studies. Data were extracted from electronic health records of 0- to 21-year-olds assigned 1 of 15 maltreatment-related International Classification of Diseases, Ninth Revision, codes who had encounters in a large medical system over a 4-year period. Only 0.02% of approximately 2.5 million youth had a maltreatment-related code, replicating other studies. Results provide a dramatic contrast to much higher rates based on self-report or informant-report and referrals to Child Protective Services. Lack of documentation of maltreatment in electronic health records can lead to missed chances at early intervention, inadequate coordination of health care, insufficient allocation of resources to addressing problems related to maltreatment, and flawed public health data.

scholarly journals The International Classification of Functioning, Disability and Health (ICF) in Electronic Health Records

2017 ◽  
Vol 08 (03) ◽  
pp. 964-980
Author(s):  
Dominik Aronsky ◽  
Birgit Prodinger ◽  
Roxanne Maritz
Keyword(s):  
Electronic Health Records ◽  
International Classification ◽  
Evaluation Framework ◽  
World Health ◽  
International Classification Of Functioning ◽  
Disability And Health ◽  
Health Records ◽  
Requirement Specification ◽  
Electronic Health

Summary Background: The International Classification of Functioning, Disability and Health (ICF) is the World Health Organization’s standard for describing health and health-related states. Examples of how the ICF has been used in Electronic Health Records (EHRs) have not been systematically summarized and described yet. Objectives: To provide a systematic review of peer-reviewed literature about the ICF’s use in EHRs, including related challenges and benefits. Methods: Peer-reviewed literature, published between January 2001 and July 2015 was retrieved from Medline®, CINAHL®, Scopus®, and ProQuest® Social Sciences using search terms related to ICF and EHR concepts. Publications were categorized according to three groups: Requirement specification, development and implementation. Information extraction was conducted according to a qualitative content analysis method, deductively informed by the evaluation framework for Health Information Systems: Human, Organization and Technology-fit (HOT-fit). Results: Of 325 retrieved articles, 17 publications were included; 4 were categorized as requirement specification, 7 as development, and 6 as implementation publications. Information regarding the HOT-fit evaluation framework was summarized. Main benefits of using the ICF in EHRs were its unique comprehensive perspective on health and its interdisciplinary focus. Main challenges included the fact that the ICF is not structured as a formal terminology as well as the need for a reduced number of ICF codes for more feasible and practical use. Conclusion: Different approaches and technical solutions exist for integrating the ICF in EHRs, such as combining the ICF with other existing standards for EHR or selecting ICF codes with natural language processing. Though the use of the ICF in EHRs is beneficial as this review revealed, the ICF could profit from further improvements such as formalizing the knowledge representation in the ICF to support and enhance interoperability.Citation: Maritz R, Aronsky D, Prodinger B. The International Classification of Functioning, Disability and Health (ICF) in Electronic Health Records. Appl Clin Inform 2017; 8: 964–980 https://doi.org/10.4338/ACI-2017050078

scholarly journals Characterizing Sleep Disorders in an Autism-Specific Collection of Electronic Health Records

2021 ◽  
Author(s):  
Emily Singer ◽  
Beth Malow ◽  
Maria Niarchou ◽  
Lea Davis ◽  
Rebecca Johnston ◽  
...  
Keyword(s):  
Sleep Problems ◽  
International Classification Of Diseases ◽  
Autism Spectrum ◽  
Health Records ◽  
Classification Of Diseases ◽  
Icd Codes ◽  
Treatment Responses ◽  
Electronic Health ◽  
Future Work

Background: Sleep problems are common in individuals with autism spectrum disorder (ASD). This study reviews one detailed approach to querying the electronic health record (EHR). Methods: We developed methods for identifying individuals with ASD and defined their sleep problems using International Classification of Diseases (ICD) codes or key words. We examined treatment responses to melatonin. Results: Sleep problems were documented in 86% of patients and using specific keywords yielded more sleep diagnoses than ICD codes alone. About two-thirds of patients benefitted from melatonin. Conclusions: Our study provides a framework for using deidentified medical records to characterize sleep, a common co-occurring condition, in ASD. Using specific keywords could be helpful in future work that queries the EHR.

scholarly journals The Effect of Perceived Expected Satisfaction with Electronic Health Records Availability on Expected Satisfaction with Electronic Health Records Portability in a Multi-Stakeholder Environment

10.28945/3434 ◽  
2016 ◽  
Vol 11 ◽  
pp. 031-053
Author(s):  
Karoly Bozan ◽  
Pratim Datta
Keyword(s):  
Electronic Health Records ◽  
Data Sharing ◽  
International Classification Of Diseases ◽  
Optimal Care ◽  
Health Records ◽  
Patient Health ◽  
Classification Of Diseases ◽  
Electronic Health ◽  
Using Data ◽  
Multi Stakeholder

A central premise for the creation of Electronic Health Records (EHR) is ensuring the portability of patient health records across various clinical, insurance, and regulatory entities. From portability standards such as International Classification of Diseases (ICD) to data sharing across institutions, a lack of portability of health data can jeopardize optimal care and reduce meaningful use. This research empirically investigates the relationship between health records availability and portability. Using data collected from 168 medical providers and patients, we confirm the positive relationship between user perceptions of expected satisfaction with EHR availability and the expected satisfaction with portability. Our findings contribute to more informed practice by understanding how ensuring the availability of patient data by virtue of enhanced data sharing standards, device independence, and better EHR data integration can subsequently drive perceptions of portability across a multitude of stakeholders.

Angststörungen – von der ICD-10 zur ICD-11

2020 ◽  
pp. 1-5
Author(s):  
Timo D. Vloet ◽  
Marcel Romanos
Keyword(s):  
Mental Disorders ◽  
International Classification Of Diseases ◽  
International Classification ◽  
Statistical Manual ◽  
Diagnostic And Statistical Manual ◽  
Dsm 5 ◽  
Classification Of Diseases ◽  
Icd 10

Zusammenfassung. Hintergrund: Nach 12 Jahren Entwicklung wird die 11. Version der International Classification of Diseases (ICD-11) von der Weltgesundheitsorganisation (WHO) im Januar 2022 in Kraft treten. Methodik: Im Rahmen eines selektiven Übersichtsartikels werden die Veränderungen im Hinblick auf die Klassifikation von Angststörungen von der ICD-10 zur ICD-11 zusammenfassend dargestellt. Ergebnis: Die diagnostischen Kriterien der generalisierten Angststörung, Agoraphobie und spezifischen Phobien werden angepasst. Die ICD-11 wird auf Basis einer Lebenszeitachse neu organisiert, sodass die kindesaltersspezifischen Kategorien der ICD-10 aufgelöst werden. Die Trennungsangststörung und der selektive Mutismus werden damit den „regulären“ Angststörungen zugeordnet und können zukünftig auch im Erwachsenenalter diagnostiziert werden. Neu ist ebenso, dass verschiedene Symptomdimensionen der Angst ohne kategoriale Diagnose verschlüsselt werden können. Diskussion: Die Veränderungen im Bereich der Angsterkrankungen umfassen verschiedene Aspekte und sind in der Gesamtschau nicht unerheblich. Positiv zu bewerten ist die Einführung einer Lebenszeitachse und Parallelisierung mit dem Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Schlussfolgerungen: Die entwicklungsbezogene Neuorganisation in der ICD-11 wird auch eine verstärkte längsschnittliche Betrachtung von Angststörungen in der Klinik sowie Forschung zur Folge haben. Damit rückt insbesondere die Präventionsforschung weiter in den Fokus.

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