scholarly journals Discovering Clinical Information Models Online to Promote Interoperability of Electronic Health Records: A Feasibility Study of OpenEHR

10.2196/13504 ◽  
2019 ◽  
Vol 21 (5) ◽  
pp. e13504
Author(s):  
Lin Yang ◽  
Xiaoshuo Huang ◽  
Jiao Li
Keyword(s):  
Electronic Health Records ◽  
Feasibility Study ◽  
Clinical Information ◽  
Health Records ◽  
Information Models ◽  
Electronic Health

scholarly journals Propuesta metodológica de intercambio electrónico de información clínica basada en estándares de telemedicina/Methodological proposal of electronic data interchange and clinical information based on telemedicine standards

2020 ◽  
Author(s):  
P. Moreno ◽  
G. Bastidas ◽  
P. Moreno
Keyword(s):  
Electronic Health Records ◽  
Information And Communication Technologies ◽  
Web Application ◽  
Medical Information ◽  
Reference Model ◽  
Clinical Information ◽  
Electronic Data Interchange ◽  
Records Management ◽  
Health Records ◽  
Electronic Health

El avance de las tecnologías de la información ha permitido un cambio sustancial en el desarrollo de la Salud, por lo que el uso de estándares de telemedicina como el HL7 y CEN TC 251-13606 permiten que los sistemas de información médica se comuniquen vía mensajes estandarizados facilitando el uso de los mismos. El propósito de este estudio es crear una guía metodológica de intercambio electrónico de información clínica basada en el análisis de los estándares de telemedicina HL7 y CEN TC 251- 13606 para mejorar la eficiencia de la gestión de Historias Clínicas de los pacientes. La metodología consta de 2 fases, la primera plantea el diseño e implementación del modelo de referencia de la Historia Clínica Electrónica, el mismo que define entidades necesarias en la construcción de una Historia Clínica Electrónica, en la fase 2 se define la arquitectura de la historia clínica especificando la estructura y semántica del documento mediante el lenguaje XML, el cual se utiliza en los procesos de gestión de las historias clínicas electrónicas dentro del sistema médico desarrollado. Este sistema permite control clínico a distancia facilitando la interacción médico-paciente. El sistema posee una aplicación web, una aplicación de escritorio y una plataforma hardware e- Salud. La aplicación de la metodología planteada mejora la eficiencia de la gestión de historias clínicas, puesto que el 83.32% de los médicos de la clínica consideran que se agiliza el proceso de acceso, creación e ingreso de historias clínicas y reduce recursos en el proceso de control de pacientes domiciliarios. The advance of Information and Communication Technologies has improved Health Care in last years; by providing new ways of accessing medical information. In particular, the use of telemedicine standards such as HL7 and CENTC 251-13606 allows standard communication, integration, and retrieval of electronic health records among medical systems. This article aims to create a methodological guide for the electronic exchange of clinical information based on telemedicine standards in order to improve the efficiency of electronic health records management. The proposed methodology consists of two phases: The first one states the design and implementation of the reference model of an electronic health records, which defines entities of the electronic health record. In phase 2, this methodology describes electronic health records architecture. The architecture is defined by the structure and semantics of the document using XML. In order to test the proposed methodology, a medical system was implemented that consists of a web application, desktop application, and hardware platform e- Health. This system allows the electronic exchange of clinical information to ease patient-doctor interaction. The results show 83,32% of doctors at the clinic where the system was tested agree the proposed methodology for electronic exchange improves the efficiency of electronic health records management since it speeds up the process of creation and retrieval of an electronic health records. Moreover, the system reduces resources in the control of home patients. Palabras clave: Telemedicina, HCE, HL7, CENTC 251-13606, e-Salud. Keywords: Telemedicine, EHR, HL7, CENTC 251-13606, e-Health.

scholarly journals Caducidad de un documento escrito en handoff

2019 ◽  
Vol 11 (1) ◽  
pp. 4
Author(s):  
Estefanía Chamorro García ◽  
Inmaculada Hernández García ◽  
Ana Isabel Galve Marqués ◽  
Pilar Cabrerizo Torrente
Keyword(s):  
Electronic Health Records ◽  
Real Time ◽  
Medical Errors ◽  
Clinical Information ◽  
Health Records ◽  
Inaccurate Information ◽  
Surgical Services ◽  
Electronic Health ◽  
Impact Patient Care ◽  
Medical Teams

El “handoff” o “pase del paciente” se define como el intercambio de información clínica cuando un nuevo médico o equipo médico asume el manejo de un paciente, bien sea de forma oral o escrita. La transmisión de información (handoff) oral, es una fuente de errores de comunicación y debe mejorar para disminuir los errores y los eventos adversos. La naturaleza estática de los documentos escritos hace que rápidamente la información se desactualice aumentando el error. Los documentos de handoff electrónicos, integrados en la historia clínica se han asociado con mejoras. La impresión hace que la actualización de los datos a tiempo real sea prácticamente imposible, incrementando el riesgo de una información inexacta. El objetivo del estudio fue determinar el tiempo en el que los datos clínicos del documento escrito se vuelven imprecisos, caracterizar el tipo de imprecisiones e identificar diferencias entre los turnos de día y de noche, así como entre servicios médicos y quirúrgicos. La hipótesis afirmaba que al final del turno de noche, la mayoría de los documentos de handoff contenían al menos un error, con potencial de producir daño. Se usó el término de “vida media”. Documentando estas imprecisiones, los autores esperaron que existiera la posibilidad de actualizar los datos en la historia clínica electrónica a tiempo real, con el objetivo de mejorar la seguridad del paciente. ABSTRACT  Expiry of a handoff printed document The handoff is defined as the change of clinical information about patients for whom physicians are responsible for between doctors and medical teams, both printed and verbal. Medical errors related to poor communication remain unacceptably common. Verbal handoffs are known to be high-risk source of communication errors and it may be improved to reduce adverse events. The static nature of printed documents makes it likely that some of the information will quickly become inaccurate, increasing the potential for medical errors. Computerised handoff documents integrated with electronic health records have been associated with improvements. Printing makes real-time automatic updating impossible, and therefore, increases the potential for inaccurate information. The main goals of this study were to measure the average time to potential inaccuracy of a printed handoff, to determine the types of inaccuracy and to identify differences between day and night shifts, as well as surgical and non-surgical services. They hypothesized that by the end of an overnight call shift, most handoffs documents would contain at least one error, which had the potential to impact patient care. They used the term  “half-life”. By documenting the inaccuracies which can be expected on printed handoff documents, the authors hope to achieve a shift toward reliance on the electronic health records on screen real, real-time, with the ultimate desired result of improved patient safety.

scholarly journals Using de-identified electronic health records to research mental health supported housing services: A feasibility study

PLoS ONE ◽  
2020 ◽  
Vol 15 (8) ◽  
pp. e0237664
Author(s):  
Christian Dalton-Locke ◽  
Johan H. Thygesen ◽  
Nomi Werbeloff ◽  
David Osborn ◽  
Helen Killaspy
Keyword(s):  
Mental Health ◽  
Electronic Health Records ◽  
Feasibility Study ◽  
Supported Housing ◽  
Health Records ◽  
Housing Services ◽  
Electronic Health

scholarly journals Clinical and Para Clinical Information Needs of Infertility Electronic Health Records in Iran: A Delphi Study

2017 ◽  
Vol 25 (3) ◽  
pp. 163
Author(s):  
Mehrdad Farzandipour ◽  
Fateme Jeddi ◽  
Hamid Gilasi ◽  
Diana Shirzadi
Keyword(s):  
Electronic Health Records ◽  
Delphi Study ◽  
Information Needs ◽  
Clinical Information ◽  
Health Records ◽  
Electronic Health

scholarly journals Evidence of gender bias in the diagnosis and management of COVID-19 patients: A Big Data analysis of Electronic Health Records

2020 ◽  
Author(s):  
Julio Ancochea ◽  
Jose L. Izquierdo ◽  
Joan B Soriano ◽  
Keyword(s):  
Electronic Health Records ◽  
Gender Gap ◽  
Disease Onset ◽  
Clinical Information ◽  
Special Focus ◽  
Free Text ◽  
Health Records ◽  
Diagnosis And Management ◽  
La Mancha ◽  
Electronic Health

Background: It remains unknown whether the frequency and severity of COVID-19 affect women differently than men. Here, we aim to describe the characteristics of COVID-19 patients at disease onset, with special focus on the diagnosis and management of female patients with COVID-19. Methods: We explored the unstructured free text in the electronic health records (EHRs) within the SESCAM Healthcare Network (Castilla La-Mancha, Spain). The study sample comprised the entire population with available EHRs (1,446,452 patients) from January 1st to May 1st, 2020. We extracted patients' clinical information upon diagnosis, progression, and outcome for all COVID-19 cases. Results: A total of 4,780 patients with a test-confirmed diagnosis of COVID-19 were identified. Of these, 2,443 (51%) were female, who were on average 1.5 years younger than males (61.7±19.4 vs. 63.3±18.3, p=0.0025). There were more female COVID-19 cases in the 15-59 yr.-old interval, with the greatest sex ratio (SR; 95% CI) observed in the 30-39 yr.-old interval (1.69; 1.35-2.11). Upon diagnosis, headache, anosmia, and ageusia were significantly more frequent in females than males. Imaging by chest X-ray or blood tests were performed less frequently in females (65.5% vs. 78.3% and 49.5% vs. 63.7%, respectively), all p<0.001. Regarding hospital resource use, females showed less frequency of hospitalization (44.3% vs. 62.0%) and ICU admission (2.8% vs. 6.3%) than males, all p<0.001. Conclusion: Our results indicate important sex-dependent differences in the diagnosis, clinical manifestation, and treatment of patients with COVID-19. These results warrant further research to identify and close the gender gap in the ongoing pandemic.

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