scholarly journals Using a Scripted Data Entry Process to Transfer Legacy Immunization Data While Transitioning Between Electronic Medical Record Systems

2014 ◽  
Vol 05 (01) ◽  
pp. 284-298 ◽  
Author(s):  
A. Hsiao ◽  
A. Fenick ◽  
J. Michel
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Data Transfer ◽  
Clinical Care ◽  
Data Entry ◽  
Data Migration ◽  
Legacy Systems ◽  
The Future ◽  
Electronic Medical Record Systems ◽  
Manual Data Entry

SummaryBackground: Transitioning between Electronic Medical Records (EMR) can result in patient data being stranded in legacy systems with subsequent failure to provide appropriate patient care. Manual chart abstraction is labor intensive, error-prone, and difficult to institute for immunizations on a systems level in a timely fashion.Objectives: We sought to transfer immunization data from two of our health system’s soon to be replaced EMRs to the future EMR using a single process instead of separate interfaces for each facility.Methods: We used scripted data entry, a process where a computer automates manual data entry, to insert data into the future EMR. Using the Center for Disease Control’s CVX immunization codes we developed a bridge between immunization identifiers within our system’s EMRs. We performed a two-step process evaluation of the data transfer using automated data comparison and manual chart review.Results: We completed the data migration from two facilities in 16.8 hours with no data loss or corruption. We successfully populated the future EMR with 99.16% of our legacy immunization data – 500,906 records – just prior to our EMR transition date. A subset of immunizations, first recognized during clinical care, had not originally been extracted from the legacy systems. Once identified, this data – 1,695 records – was migrated using the same process with minimal additional effort.Conclusions: Scripted data entry for immunizations is more accurate than published estimates for manual data entry and we completed our data transfer in 1.2% of the total time we predicted for manual data entry. Performing this process before EMR conversion helped identify obstacles to data migration. Drawing upon this work, we will reuse this process for other healthcare facilities in our health system as they transition to the future EMR.Citation: Michel J, Hsiao A, Fenick A. Using a scripted data entry process to transfer legacy immunization data while transitioning between electronic medical record systems. Appl Clin Inf 2014; 5: 284–298 http://dx.doi.org/10.4338/ACI-2013-11-RA-0096

A clinically useful diabetes electronic medical record: Lessons from the past; pointers toward the future

1996 ◽  
Vol 134 (1) ◽  
pp. 31-42 ◽  
Author(s):  
Colum Gorman ◽  
James Looker ◽  
Tom Fisk ◽  
William Oelke ◽  
David Erickson ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Data Entry ◽  
Clinical Encounter ◽  
Free Text ◽  
Diabetes Clinic ◽  
The Past ◽  
The Future ◽  
Patients With Diabetes ◽  
On Line

Gorman C, Looker J, Fisk T, Oelke W, Erickson D, Smith S, Zimmerman B. A clinically useful diabetes electronic medical record. Lessons from the past; pointers toward the future. Eur J Endocrinol 1996;134:31–42. ISSN 0804–4643 We have analysed the deficiencies of paper medical records in facilitating the care of patients with diabetes and have developed an electronic medical record that corrects some of them. The diabetes electronic medical record (DEMR) is designed to facilitate the work of a busy diabetes clinic. Design principles include heavy reliance on graphic displays of laboratory and clinical data, consistent color coding and aggregation of data needed to facilitate the different types of clinical encounter (initial consultation, continuing care visit, insulin adjustment visit, dietitian encounter, nurse educator encounter, obstetric patient, transplant patient, visits for problems unrelated to diabetes). Data input is by autoflow from the institutional laboratories, by desk attendants or on-line by all users. Careful attention has been paid to making data entry a point and click process wherever possible. Opportunity for free text comment is provided on every screen. On completion of the encounter a narrative text summary of the visit is generated by the computer and is annotated by the care giver. Currently there are about 7800 patients in the system. Remaining challenges include the adaptation of the system to accommodate the occasional user, development of portable laptop derivatives that remain compatible with the parent system and improvements in the screen structure and graphic display formats. Colum Gorman, Division of Endocrinology and Metabolism, Mayo Clinic, Rochester. MN. USA

Virtuelle Medizin in der Behandlung von Sucht in den USA, Kanada und darüber hinaus

Suchttherapie ◽  
2020 ◽  
Vol 21 (04) ◽  
pp. 189-193
Author(s):  
R. Michael Krausz ◽  
Farhud Shams ◽  
Maurice Cabanis
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Record Systems

ZusammenfassungInsbesondere während der aktuellen Corona-Pandemie hat der Gebrauch virtueller Lösungen in der Medizin international stark zugenommen. Es gibt eine zunehmende Akzeptanz gerade auch in dem Bereich der hausärztlichen Versorgung, der Behandlung psychischer Störungen und der Abhängigkeitserkrankungen.Die Entwicklung ist international unterschiedlich, v. a, wenn man die USA und Kanada auf der einen Seite und Europa, insbesondere Deutschland, andererseits vergleicht. In Nordamerika hat bei dem Einsatz von moderner Technologie die Einführung von „Electronic Medical Record Systems“ eine dominierende Rolle gespielt. Diese ist insbesondere auf Abrechnung und Dokumentation zu Versicherungszwecken fokussiert. Daneben gibt es zunehmend Apps, die spezifische therapeutische Ansätze zu implementieren helfen. Die Anwendung virtueller Ansätze im Suchtbereich ist begrenzt, aber in Teilen sehr innovativ und auf deutsche Verhältnisse anwendbar. Wie in Europa gibt es auch in Nordamerika nur sehr begrenzte Forschungskapazitäten und prinzipiell Widerstand bei den medizinischen Berufsgruppen bezüglich der Anwendungsmöglichkeiten und der Rolle im Behandlungsprozess. Mehr Kooperation würde international zu einer Beschleunigung der Entwicklung und der Etablierung gemeinsamer Standards beitragen sowie die Behandlungssysteme bedeutend verbessern.

scholarly journals Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing

JAMA Surgery ◽  
2018 ◽  
Vol 153 (11) ◽  
pp. 1012 ◽  
Author(s):  
Alexander S. Chiu ◽  
Raymond A. Jean ◽  
Jessica R. Hoag ◽  
Mollie Freedman-Weiss ◽  
James M. Healy ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Opioid Prescribing ◽  
Pill Counts ◽  
Electronic Medical Record Systems

Consultation of Medical Narratives in the Electronic Medical Record

1999 ◽  
Vol 38 (04/05) ◽  
pp. 289-293 ◽  
Author(s):  
H. J. Tange
Keyword(s):  
Information Retrieval ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Data Entry ◽  
Daily Practice ◽  
Evaluation Study ◽  
System Level ◽  
Free Text ◽  
Patient Case ◽  
Medical Narratives

AbstractThis article presents an overview of a research project concerning the consultation of medical narratives in the electronic medical record (EMR). It describes an analysis of user needs, the design and implementation of a prototype EMR system, and the evaluation of the ease of consultation of medical narratives when using this system. In a questionnaire survey, 85 hospital physicians judged the quality of their paper-based medical record with respect to data entry, information retrieval and some other aspects. Participants were more positive about the paper medical record than the literature suggests. They wished to maintain the flexibility of data entry but indicated the need to improve the retrieval of information. A prototype EMR system was developed to facilitate the consultation of medical narratives. These parts were divided into labeled segments that could be arranged source-oriented and problem-oriented. This system was used to evaluate the ease of information retrieval of 24 internists and 12 residents at a teaching hospital when using free-text medical narratives divided at different levels of detail. They solved, without time pressure, some predefined problems concerning three voluminous, inpatient case records. The participants were randomly allocated to a sequence that was balanced by patient case and learning effect. The division of medical narratives affected speed, but not completeness of information retrieval. Progress notes divided into problem-related segments could be consulted 22% faster than when undivided. Medical history and physical examination divided into segments at organ-system level could be consulted 13% faster than when divided into separate questions and observations. These differences were statistically significant. The fastest divisions were also appreciated as the best combination of easy searching and best insight in the patient case. The results of our evaluation study suggest a trade-off between searching and reading: too much detailed segments will delay the consultation of medical narratives. Validation of the results in daily practice is recommended.

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