Naming Notes: Transitions from Free Text to Structured Entry

1995 ◽  
Vol 34 (01/02) ◽  
pp. 57-67 ◽  
Author(s):  
J. Gregory ◽  
J. E. Mattison ◽  
C. Linde
Keyword(s):  
Health Care ◽  
Electronic Health Record ◽  
Health Care Providers ◽  
Medical Records ◽  
Care Delivery ◽  
Free Text ◽  
Development Effort ◽  
Health Record ◽  
Care Providers ◽  
Electronic Health

Abstract:To practice medicine in the near future, health care providers in the USA need an information infrastructure they do not yet have. We offer a contribution from social science research to discussions of current medical records practices and how health care activity systems may be transformed by the advent of electronic health records. The goal of the paper is to set forth a framework that connects over-arching questions concerning medical informatics systems development with the practical, cultural and conceptual issues involved in transitions from handwritten and other free text documentation to structured entry of medical records to build patient profiles. The research is broadly framed by an interest in how reciprocal modifications of the design and use of an electronic health record are negotiated in an iterative prototyping project. It is conducted as part of a complex multi-disciplinary research and development effort to create an electronic health record prototype for use in the integrated health care delivery environment of the Southern California Kaiser Permanente Medical Care Program.

scholarly journals Pattern of Use of Electronic Health Record (EHR) among the Chronically Ill: A Health Information National Trend Survey (HINTS) Analysis

2021 ◽  
Vol 18 (14) ◽  
pp. 7254
Author(s):  
Rose Calixte ◽  
Sumaiya Islam ◽  
Zainab Toteh Osakwe ◽  
Argelis Rivera ◽  
Marlene Camacho-Rivera
Keyword(s):  
Health Care ◽  
Electronic Health Record ◽  
Health Care Providers ◽  
Medical Records ◽  
Chronically Ill ◽  
Health Record ◽  
Provider Communication ◽  
Care Providers ◽  
Patient Portals ◽  
Electronic Health

Effective patient–provider communication is a cornerstone of patient-centered care. Patient portals provide an effective method for secure communication between patients or their proxies and their health care providers. With greater acceptability of patient portals in private practices, patients have a unique opportunity to manage their health care needs. However, studies have shown that less than 50% of patients reported accessing the electronic health record (EHR) in a 12-month period. We used HINTS 5 cycle 1 and cycle 2 to assess disparities among US residents 18 and older with any chronic condition regarding the use of EHR for secure direct messaging with providers, to request refills, to make clinical decisions, or to share medical records with another provider. The results indicate that respondents with multimorbidity are more likely to share their medical records with other providers. However, respondents who are 75 and older are less likely to share their medical records with another provider. Additionally, respondents who are 65 and older are less likely to use the EHR for secure direct messaging with their provider. Additional health care strategies and provider communication should be developed to encourage older patients with chronic conditions to leverage the use of patient portals for effective disease management.

Electronic Health Records in Developing Countries: The Role Of Intelligent Devices

2020 ◽  
Vol 27 (1) ◽  
Author(s):  
O Kalesanwo ◽  
SO Kuyoro ◽  
D Aleburu ◽  
VO Nwaocha ◽  
AA Adenrele
Keyword(s):  
Health Care ◽  
Developing Countries ◽  
Electronic Health Record ◽  
Health Care Providers ◽  
Intelligent Systems ◽  
Easy Access ◽  
Health Record ◽  
Care Providers ◽  
Intelligent Devices ◽  
Electronic Health

The collection and storing of medical records pertaining to the health status of patients in an electronic form so as to allow; easy access, information sharing and making better medical decisions among other things is known as an Electronic Health Record (EHR). Data generated by health care providers from patient‟s diagnosis, prescription, health monitoring and other health related issues were basically kept on paper. However, the rapid proliferation of data has led to the advancement of effective management of these data to help bring about better decision making and also improvement in health care delivery. This paper highlights the importance of EHR, its role in delivering better health care and the development of a nation, taking cognizance of its adoption level in both the developed and developing countries. Strategic solution of integrating intelligent devices (Chatbots and glass) to burgeon the implementation of EHR so as to improve the overall health care of the populace of developing nations was proposed. Keywords: Electronic Health Record, Intelligent systems, Chatbots, Glass

Words Matter

2016 ◽  
Vol 85 (1) ◽  
pp. 123-130 ◽  
Author(s):  
Rachael Spalding ◽  
Elissa Kozlov ◽  
Brian D. Carpenter
Keyword(s):  
Health Care ◽  
Electronic Health Record ◽  
Health Care Providers ◽  
Subsequent Treatment ◽  
Health Record ◽  
Care Providers ◽  
Linguistic Features ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Electronic Health

Palliative care consultation teams (PCCTs) provide input to other health-care providers working with patients who have life-limiting disease. This study examines whether the diction and phrasing of consultation recommendations in the electronic health record influence their implementation. We reviewed 288 verbatim PCCT recommendations that were made for 111 unique patients in a Veterans Affairs hospital and available in the electronic health record. Recommendations were coded for linguistic features, such as the presence of conditionals (e.g., “could”) and tentative phrasing (e.g., “would suggest”). Each patient’s subsequent treatment was followed in the medical record to determine whether PCCT recommendations were implemented. Only 57% of the consultation recommendations were eventually implemented. Recommendations that included a conditional word or phrase were significantly less likely to be implemented. In particular, recommendations that included the words “could” and “consider” were less likely to be implemented. PCCTs may enhance their effectiveness by attending to the subtle pragmatics of how they communicate with other health-care providers, particularly in electronic communication where nonverbal features of communication are unavailable.

Mastering Electronic Health Record in Global Health Care

2017 ◽  
pp. 222-242 ◽  
Author(s):  
Kijpokin Kasemsap
Keyword(s):  
Health Care ◽  
Global Health ◽  
Electronic Health Record ◽  
Health Care Providers ◽  
Clinical Decision ◽  
Health Record ◽  
Care Providers ◽  
Global Health Care ◽  
Electronic Health ◽  
The One

This chapter describes the overview of electronic health record (EHR); the trends and issues with EHR; EHR and clinical decision support system (CDSS); the trust and privacy concerns of EHR systems; and the significance of EHR in global health care. EHR systems are very important in health care settings and have the potential to transform the health care system from a mostly paper-based industry to the one that utilizes the clinical data and other pieces of information to assist health care providers in delivering the higher quality of care to their patients. EHRs and their ability to electronically exchange health information can help health care providers effectively provide higher quality and safer care for patients while creating tangible enhancements in global health care.

Electronic Health Record Reminders for Chlamydia Screening in an American Indian Population

2020 ◽  
pp. 003335492097094
Author(s):  
Michael Sang Hughes ◽  
Andria Apostolou ◽  
Brigg Reilley ◽  
Jessica Leston ◽  
Jeffrey McCollum ◽  
...  
Keyword(s):  
Health Care ◽  
Electronic Health Record ◽  
Health Care Providers ◽  
Chlamydia Screening ◽  
Health Record ◽  
Care Providers ◽  
Female Patients ◽  
Screening Performance ◽  
Electronic Health ◽  
Clinical Departments

Objectives Indian Health Service (IHS) screening rates for Chlamydia trachomatis are lower than national rates of chlamydia screening in the Southwest. We describe and evaluate the effect of a public health intervention consisting of electronic health record (EHR) reminders to alert health care providers to screen for chlamydia at an IHS facility. We also conducted an awareness presentation among health care providers on chlamydia screening. Methods We conducted our intervention from November 1, 2013, through October 31, 2015, at an IHS facility in the Southwest. We implemented algorithms that queried database values to assess chlamydia screening performance in 6 clinical departments. We presented data on the screening performance of clinical departments and health care providers (de-identified) in the awareness presentations. We re-queried database values 1 and 2 years after implementation of the EHR reminder intervention to evaluate before-and-after screening rates, comparing data among all patients and among female patients only. Results We found small, sustained relative increases in chlamydia screening rates during the 2012-2015 evaluation period: 20.8% pre-intervention to 24.9% and 24.2% one and two years postintervention, respectively, across all patients; 32.3% preintervention to 36.6% and 35.6% one and two years postintervention, respectively, among female patients. Increases in clinical department–specific screening rates varied and were most prominent in internal medicine (35.8% preintervention to peak 65.8% postintervention). The 1 clinic (obstetrics–gynecology) that did not receive an awareness presentation showed a consistent downward trend in screening rates, although absolute rates were consistently higher in that clinic than in other clinics. Conclusions Awareness presentations that offer feedback to health care providers on screening performance, heighten provider awareness of the importance of chlamydia screening, and promote development of novel provider-initiated screening protocols may help to increase screening rates when combined with EHR reminders.

Mastering Electronic Health Record in Global Health Care

2017 ◽  
pp. 1091-1111
Author(s):  
Kijpokin Kasemsap
Keyword(s):  
Health Care ◽  
Global Health ◽  
Electronic Health Record ◽  
Health Care Providers ◽  
Clinical Decision ◽  
Health Record ◽  
Care Providers ◽  
Global Health Care ◽  
Electronic Health ◽  
The One

This chapter describes the overview of electronic health record (EHR); the trends and issues with EHR; EHR and clinical decision support system (CDSS); the trust and privacy concerns of EHR systems; and the significance of EHR in global health care. EHR systems are very important in health care settings and have the potential to transform the health care system from a mostly paper-based industry to the one that utilizes the clinical data and other pieces of information to assist health care providers in delivering the higher quality of care to their patients. EHRs and their ability to electronically exchange health information can help health care providers effectively provide higher quality and safer care for patients while creating tangible enhancements in global health care.

scholarly journals The Perceptions of and Factors Associated With the Adoption of the Electronic Health Record Sharing System Among Patients and Physicians: Cross-Sectional Survey (Preprint)

2019 ◽  
Author(s):  
Martin CS Wong ◽  
Junjie Huang ◽  
Paul SF Chan ◽  
Veeleah Lok ◽  
Colette Leung ◽  
...  
Keyword(s):  
Health Care ◽  
Electronic Health Record ◽  
Service Providers ◽  
Care Delivery ◽  
Health Care Service ◽  
Health Record ◽  
Public And Private ◽  
Major Barrier ◽  
Factors Associated ◽  
Electronic Health

BACKGROUND The electronic health record sharing system (eHRSS) was implemented as a new health care delivery platform to facilitate two-way communication between the public and private sectors in Hong Kong. OBJECTIVE This study aimed to investigate the perceptions of and factors associated with the adoption of eHRSS among patients, the general public, and private physicians. METHODS Telephone interviews were conducted in 2018 by using a simple random sampling strategy from a list of patients who had enrolled in the eHRSS and a territory-wide telephone directory for nonenrolled residents. We completed 2000 surveys (1000 each for enrolled and nonenrolled individuals). Private physicians completed self-administered questionnaires, including 762 valid questionnaires from 454 enrolled physicians and 308 nonenrolled physicians. RESULTS Most participants (707/1000, 70.70%) were satisfied with the overall performance of the eHRSS. Regarding registration status, most nonenrolled patients (647/1000, 64.70%) reported that “no recommendation from their physicians and family members” was the major barrier, whereas more than half of the physicians (536/1000, 53.60%) expressed concerns on “additional workload due to use of eHRSS.” A multivariate regression analysis showed that patients were more likely to register when they reported “other service providers could view the medical records” (adjusted odds ratio [aOR] 6.09, 95% CI 4.87-7.63; <i>P</i>&lt;.001) and “friends’ or family’s recommendation or assistance in registration” (aOR 3.51, 95% CI 2.04-6.03; <i>P</i>=.001). Physicians were more likely to register when they believed that the eHRSS could improve the quality of health care service (aOR 4.70, 95% CI 1.77-12.51; <i>P</i>=.002) and were aware that the eHRSS could reduce duplicated tests and treatments (aOR 4.16, 95% CI 1.73-9.97; <i>P</i>=.001). CONCLUSIONS Increasing the possibility of viewing patients' personal medical record, expanding the sharable data scope for patients, and highlighting the benefits of the system for physicians could be effective to enhance the adoption of the eHRSS.

scholarly journals Implementing electronic health records (EHRs): health care provider perceptions before and after transition from a local basic EHR to a commercial comprehensive EHR

2017 ◽  
Vol 25 (6) ◽  
pp. 618-626 ◽  
Author(s):  
Marie Krousel-Wood ◽  
Allison B McCoy ◽  
Chad Ahia ◽  
Elizabeth W Holt ◽  
Donnalee N Trapani ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Preventive Care ◽  
Care Delivery ◽  
Primary Care Providers ◽  
Easy Access ◽  
Care Providers ◽  
Before And After ◽  
Electronic Health

Abstract Objective We assessed changes in the percentage of providers with positive perceptions of electronic health record (EHR) benefit before and after transition from a local basic to a commercial comprehensive EHR. Methods Changes in the percentage of providers with positive perceptions of EHR benefit were captured via a survey of academic health care providers before (baseline) and at 6–12 months (short term) and 12–24 months (long term) after the transition. We analyzed 32 items for the overall group and by practice setting, provider age, and specialty using separate multivariable-adjusted random effects logistic regression models. Results A total of 223 providers completed all 3 surveys (30% response rate): 85.6% had outpatient practices, 56.5% were &gt;45 years old, and 23.8% were primary care providers. The percentage of providers with positive perceptions significantly increased from baseline to long-term follow-up for patient communication, hospital transitions – access to clinical information, preventive care delivery, preventive care prompt, preventive lab prompt, satisfaction with system reliability, and sharing medical information (P &lt; .05 for each). The percentage of providers with positive perceptions significantly decreased over time for overall satisfaction, productivity, better patient care, clinical decision quality, easy access to patient information, monitoring patients, more time for patients, coordination of care, computer access, adequate resources, and satisfaction with ease of use (P &lt; 0.05 for each). Results varied by subgroup. Conclusion After a transition to a commercial comprehensive EHR, items with significant increases and significant decreases in the percentage of providers with positive perceptions of EHR benefit were identified, overall and by subgroup.

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