Quantifying clinical narrative redundancy in an electronic health record

Objective

Although electronic notes have advantages compared to handwritten notes, they take longer to write and promote information redundancy in electronic health records (EHRs). We sought to quantify redundancy in clinical documentation by studying collections of physician notes in an EHR.

Design and methods

We implemented a retrospective design to gather all electronic admission, progress, resident signout and discharge summary notes written during 100 randomly selected patient admissions within a 6 month period. We modified and applied a Levenshtein edit-distance algorithm to align and compare the documents written for each of the 100 admissions. We then identified and measured the amount of text duplicated from previous notes. Finally, we manually reviewed the content that was conserved between note types in a subsample of notes.

Measurements

We measured the amount of new information in a document, which was calculated as the number of words that did not match with previous documents divided by the length, in words, of the document. Results are reported as the percentage of information in a document that had been duplicated from previously written documents.

Results

Signout and progress notes proved to be particularly redundant, with an average of 78% and 54% information duplicated from previous documents respectively. There was also significant information duplication between document types (eg, from an admission note to a progress note).

Conclusion

The study established the feasibility of exploring redundancy in the narrative record with a known sequence alignment algorithm used frequently in the field of bioinformatics. The findings provide a foundation for studying the usefulness and risks of redundancy in the EHR.     

Health Professionals Expose TB Patients to Stigmatization in Society: Insights from Communities in an Urban District in Ghana

Objectives

To determine how the activities and attitudes of health professionals expose TB patients to stigmatization in the community.

Design

Qualitative research approach using individual interviews and focus groups

Setting

Shama Ahanta East Metropolitan district in the western region of Ghana

Participants

Members in nine communities in the district

Outcome measures

Words and statements that depict how activities and attitudes of health professionals may expose TB patients to stigmatization

Results

Five interrelated ways by which activities and attitudes of health professionals may expose TB patients to stigmatization in the community were identified in data: TB control practices; fear-based responses to TB; inappropriate health education messages; medical licensing for sellers; and prohibition of burial rites.

Conclusions

The findings may explain the diagnostic delay and low TB case detection rate in Ghana. This calls for intensification of education on TB and regular organization of refresher courses and possibly retraining of health professionals in TB control and management. When health professionals are seen to be treating TB patients as ‘normal’ individuals, it has the potential of changing the society''s perception about the disease.     

Research and applications: Phenotyping for patient safety: algorithm development for electronic health record based automated adverse event and medical error detection in neonatal intensive care

Background

Although electronic health records (EHRs) have the potential to provide a foundation for quality and safety algorithms, few studies have measured their impact on automated adverse event (AE) and medical error (ME) detection within the neonatal intensive care unit (NICU) environment.

Objective

This paper presents two phenotyping AE and ME detection algorithms (ie, IV infiltrations, narcotic medication oversedation and dosing errors) and describes manual annotation of airway management and medication/fluid AEs from NICU EHRs.

Methods

From 753 NICU patient EHRs from 2011, we developed two automatic AE/ME detection algorithms, and manually annotated 11 classes of AEs in 3263 clinical notes. Performance of the automatic AE/ME detection algorithms was compared to trigger tool and voluntary incident reporting results. AEs in clinical notes were double annotated and consensus achieved under neonatologist supervision. Sensitivity, positive predictive value (PPV), and specificity are reported.

Results

Twelve severe IV infiltrates were detected. The algorithm identified one more infiltrate than the trigger tool and eight more than incident reporting. One narcotic oversedation was detected demonstrating 100% agreement with the trigger tool. Additionally, 17 narcotic medication MEs were detected, an increase of 16 cases over voluntary incident reporting.

Conclusions

Automated AE/ME detection algorithms provide higher sensitivity and PPV than currently used trigger tools or voluntary incident-reporting systems, including identification of potential dosing and frequency errors that current methods are unequipped to detect.     

Behavioral health providers' beliefs about health information exchange: a statewide survey

Objective

To assess behavioral health providers'' beliefs about the benefits and barriers of health information exchange (HIE).

Methods

Survey of a total of 2010 behavioral health providers in a Midwestern state (33% response rate), with questions based on previously reported open-ended beliefs elicitation interviews.

Results

Factor analysis resulted in four groupings: beliefs that HIE would improve care and communication, add cost and time burdens, present access and vulnerability concerns, and impact workflow and control (positively and negatively). A regression model including all four factors parsimoniously predicted attitudes toward HIE. Providers clustered into two groups based on their beliefs: a majority (67%) were positive about the impact of HIE, and the remainder (33%) were negative. There were some professional/demographic differences between the two clusters of providers.

Discussion

Most behavioral health providers are supportive of HIE; however, their adoption and use of it may continue to lag behind that of medical providers due to perceived cost and time burdens and concerns about access to and vulnerability of information.     

Use of a support vector machine for categorizing free-text notes: assessment of accuracy across two institutions

Background

Electronic health record (EHR) users must regularly review large amounts of data in order to make informed clinical decisions, and such review is time-consuming and often overwhelming. Technologies like automated summarization tools, EHR search engines and natural language processing have been shown to help clinicians manage this information.

Objective

To develop a support vector machine (SVM)-based system for identifying EHR progress notes pertaining to diabetes, and to validate it at two institutions.

Materials and methods

We retrieved 2000 EHR progress notes from patients with diabetes at the Brigham and Women''s Hospital (1000 for training and 1000 for testing) and another 1000 notes from the University of Texas Physicians (for validation). We manually annotated all notes and trained a SVM using a bag of words approach. We then used the SVM on the testing and validation sets and evaluated its performance with the area under the curve (AUC) and F statistics.

Results

The model accurately identified diabetes-related notes in both the Brigham and Women''s Hospital testing set (AUC=0.956, F=0.934) and the external University of Texas Faculty Physicians validation set (AUC=0.947, F=0.935).

Discussion

Overall, the model we developed was quite accurate. Furthermore, it generalized, without loss of accuracy, to another institution with a different EHR and a distinct patient and provider population.

Conclusions

It is possible to use a SVM-based classifier to identify EHR progress notes pertaining to diabetes, and the model generalizes well.     

Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

Background

Electronic health record (EHR) adoption is a national priority in the USA, and well-designed EHRs have the potential to improve quality and safety. However, physicians are reluctant to implement EHRs due to financial constraints, usability concerns, and apprehension about unintended consequences, including the introduction of medical errors related to EHR use. The goal of this study was to characterize and describe physicians'' attitudes towards three consequences of EHR implementation: (1) the potential for EHRs to introduce new errors; (2) improvements in healthcare quality; and (3) changes in overall physician satisfaction.

Methods

Using data from a 2007 statewide survey of Massachusetts physicians, we conducted multivariate regression analysis to examine relationships between practice characteristics, perceptions of EHR-related errors, perceptions of healthcare quality, and overall physician satisfaction.

Results

30% of physicians agreed that EHRs create new opportunities for error, but only 2% believed their EHR has created more errors than it prevented. With respect to perceptions of quality, there was no significant association between perceptions of EHR-associated errors and perceptions of EHR-associated changes in healthcare quality. Finally, physicians who believed that EHRs created new opportunities for error were less likely be satisfied with their practice situation (adjusted OR 0.49, p=0.001).

Conclusions

Almost one third of physicians perceived that EHRs create new opportunities for error. This perception was associated with lower levels of physician satisfaction.     

Performance factors of mobile rich media job aids for community health workers

Objective

To study and analyze the possible benefits on performance of community health workers using point-of-care clinical guidelines implemented as interactive rich media job aids on small-format mobile platforms.

Design

A crossover study with one intervention (rich media job aids) and one control (traditional job aids), two periods, with 50 community health workers, each subject solving a total 15 standardized cases per period per period (30 cases in total per subject).

Measurements

Error rate per case and task, protocol compliance.

Results

A total of 1394 cases were evaluated. Intervention reduces errors by an average of 33.15% (p=0.001) and increases protocol compliance 30.18% (p<0.001).

Limitations

Medical cases were presented on human patient simulators in a laboratory setting, not on real patients.

Conclusion

These results indicate encouraging prospects for mHealth technologies in general, and the use of rich media clinical guidelines on cell phones in particular, for the improvement of community health worker performance in developing countries.     

Benchmarking health IT among OECD countries: better data for better policy

Objective

To develop benchmark measures of health information and communication technology (ICT) use to facilitate cross-country comparisons and learning.

Materials and methods

The effort is led by the Organisation for Economic Co-operation and Development (OECD). Approaches to definition and measurement within four ICT domains were compared across seven OECD countries in order to identify functionalities in each domain. These informed a set of functionality-based benchmark measures, which were refined in collaboration with representatives from more than 20 OECD and non-OECD countries. We report on progress to date and remaining work to enable countries to begin to collect benchmark data.

Results

The four benchmarking domains include provider-centric electronic record, patient-centric electronic record, health information exchange, and tele-health. There was broad agreement on functionalities in the provider-centric electronic record domain (eg, entry of core patient data, decision support), and less agreement in the other three domains in which country representatives worked to select benchmark functionalities.

Discussion

Many countries are working to implement ICTs to improve healthcare system performance. Although many countries are looking to others as potential models, the lack of consistent terminology and approach has made cross-national comparisons and learning difficult.

Conclusions

As countries develop and implement strategies to increase the use of ICTs to promote health goals, there is a historic opportunity to enable cross-country learning. To facilitate this learning and reduce the chances that individual countries flounder, a common understanding of health ICT adoption and use is needed. The OECD-led benchmarking process is a crucial step towards achieving this.     

Openness of patients' reporting with use of electronic records: psychiatric clinicians' views

Objectives

Improvements in electronic health record (EHR) system development will require an understanding of psychiatric clinicians'' views on EHR system acceptability, including effects on psychotherapy communications, data-recording behaviors, data accessibility versus security and privacy, data quality and clarity, communications with medical colleagues, and stigma.

Design

Multidisciplinary development of a survey instrument targeting psychiatric clinicians who recently switched to EHR system use, focus group testing, data analysis, and data reliability testing.

Measurements

Survey of 120 university-based, outpatient mental health clinicians, with 56 (47%) responding, conducted 18 months after transition from a paper to an EHR system.

Results

Factor analysis gave nine item groupings that overlapped strongly with five a priori domains. Respondents both praised and criticized the EHR system. A strong majority (81%) felt that open therapeutic communications were preserved. Regarding data quality, content, and privacy, clinicians (63%) were less willing to record highly confidential information and disagreed (83%) with including their own psychiatric records among routinely accessed EHR systems.

Limitations

single time point; single academic medical center clinic setting; modest sample size; lack of prior instrument validation; survey conducted in 2005.

Conclusions

In an academic medical center clinic, the presence of electronic records was not seen as a dramatic impediment to therapeutic communications. Concerns regarding privacy and data security were significant, and may contribute to reluctances to adopt electronic records in other settings. Further study of clinicians'' views and use patterns may be helpful in guiding development and deployment of electronic records systems.     

Sociotechnical challenges to developing technologies for patient access to health information exchange data

Background

Providing patients with access to their medical data is widely expected to help educate and empower them to manage their own health. Health information exchange (HIE) infrastructures could potentially help patients access records across multiple healthcare providers. We studied three HIE organizations as they developed portals to give consumers access to HIE data previously exchanged only among healthcare organizations.

Objective

To follow the development of new consumer portal technologies, and to identify barriers and facilitators to patient access to HIE data.

Methods

Semistructured interviews of 15 key informants over a 2-year period spanning the development and early implementation of three new projects, coded according to a sociotechnical framework.

Results

As the organizations tried to develop functionality that fully served the needs of both providers and patients, plans were altered by technical barriers (primarily related to data standardization) and cultural and legal issues surrounding data access. Organizational changes also played an important role in altering project plans. In all three cases, patient access to data was significantly scaled back from initial plans.

Conclusions

This prospective study revealed how sociotechnical factors previously identified as important in health information technology success and failure helped to shape the evolution of three novel consumer informatics projects. Barriers to providing patients with seamless access to their HIE data were multifactorial. Remedies will have to address technical, organizational, cultural, and other factors.     

Health problems in elderly patients during the first post-stroke year

Background

A wide range of health problems has been reported in elderly post-stroke patients.

Aim

The aim of this study was to analyse the prevalence and timing of health problems identified by patient interviews and scrutiny of primary health care and municipality elderly health care records during the first post-stroke year.

Methods

A total of 390 consecutive patients, ≥65 years, discharged alive from hospital after a stroke event, were followed for 1 year post-admission. Information on the health care situation during the first post-stroke year was obtained from primary health care and municipal elderly health care records and through interviews with the stroke survivors, at 1 week after discharge, and 3 and 12 months after hospital admission.

Results

More than 90% had some health problem at some time during the year, while based on patient record data only 4–8% had problems during a given week. The prevalence of interview-based health problems was generally higher than record-based prevalence, and the ranking order was moderately different. The most frequently interview-reported problems were associated with perception, activity, and tiredness, while the most common record-based findings indicated pain, bladder and bowel function, and breathing and circulation problems. There was co-occurrence between some problems, such as those relating to cognition, activity, and tiredness.

Conclusions

Almost all patients had a health problem during the year, but few occurred in a given week. Cognitive and communication problems were more common in interview data than record data. Co-occurrence may be used to identify subtle health problems.     

Design and development of an international clinical data exchange system: the international layer function of the Dolphin Project

Objective

At present, most clinical data are exchanged between organizations within a regional system. However, people traveling abroad may need to visit a hospital, which would make international exchange of clinical data very useful.

Background

Since 2007, a collaborative effort to achieve clinical data sharing has been carried out at Zhejiang University in China and Kyoto University and Miyazaki University in Japan; each is running a regional clinical information center.

Methods

An international layer system named Global Dolphin was constructed with several key services, sharing patients'' health information between countries using a medical markup language (MML). The system was piloted with 39 test patients.

Results

The three regions above have records for 966 000 unique patients, which are available through Global Dolphin. Data exchanged successfully from Japan to China for the 39 study patients include 1001 MML files and 152 images. The MML files contained 197 free text-type paragraphs that needed human translation.

Discussion

The pilot test in Global Dolphin demonstrates that patient information can be shared across countries through international health data exchange. To achieve cross-border sharing of clinical data, some key issues had to be addressed: establishment of a super directory service across countries; data transformation; and unique one—language translation. Privacy protection was also taken into account. The system is now ready for live use.

Conclusion

The project demonstrates a means of achieving worldwide accessibility of medical data, by which the integrity and continuity of patients'' health information can be maintained.     

Esthetics and Biocompatibility of Composite Dental Laminates

Background

Advances in modern dental materials provide patients with a choice of natural looking veneers to provide esthetic restorations. These may be directly fabricated composite resin veneers or indirectly fabricated veneers. This study was carried out to evaluate the clinical effect of new generation indirect veneering composites and to compare them with veneers fabricated from direct composite restorations.

Methods

The present study was carried out in the Prosthodontics department of a medical college. A total of forty patients requiring restoration of the anterior teeth using composite veneers were selected and either of the two materials was used to fabricate the veneers.

Result

Clinical evaluation was done for esthetics and periodontal health. Statistical analysis showed that there were no significant changes to the periodontal health during the period of the study.

Conclusion

The evidence obtained from this study indicates that both direct as well as indirect composite materials had clinically acceptable outcomes in terms of restoration of esthetics. Biocompatibility with the periodontal tissues of both materials was also evident by the improvement in oral health indices used in the study.Key Words: Veneers, Indirect composites, Biocompatibility     

Barriers to maternal health service use in Chikhwawa,Southern Malawi

Introduction

Research was conducted to get a community''s perspective on the factors contributing to continued maternal and neonatal deaths. The aim of the study was to identify and understand experiences, perceptions and needs of the community on maternal health service utilization.

Methods

Qualitative data was obtained through focus group discussions with community leaders, women, men and youth in the catchment areas of three remote health centres. A total of fourteen focus groups were held: three each with community leaders, men, women, boys and two with girls.Data was transcribed and analyzed manually through the use of thematic analysis.

Results

The discussions revealed the following as barriers to maternal health service utilization: walking long distances to access health facilities, lack of midwives, lack of or insufficient items to be used during delivery, long stay and rude health personnel. Seeking help from Traditional Birth Attendants (TBAs) during delivery was a common option because TBAs are within reach, do not demand many items for delivery, and treat the women with respect.

Conclusion

This study suggests some factors that are contributing to the high burden of maternal deaths in Malawi. Interventions should be developed and implemented to improve the barriers reported.     

Use of the internet and an online personal health record system by US veterans: comparison of Veterans Affairs mental health service users and other veterans nationally

Objective

The Department of Veterans Affairs (VA) operates one of the largest nationwide healthcare systems and is increasing use of internet technology, including development of an online personal health record system called My HealtheVet. This study examined internet use among veterans in general and particularly use of online health information among VA patients and specifically mental health service users.

Methods

A nationally representative sample of 7215 veterans from the 2010 National Survey of Veterans was used. Logistic regression was employed to examine background characteristics associated with internet use and My HealtheVet.

Results

71% of veterans reported using the internet and about a fifth reported using My HealtheVet. Veterans who were younger, more educated, white, married, and had higher incomes were more likely to use the internet. There was no association between background characteristics and use of My HealtheVet. Mental health service users were no less likely to use the internet or My HealtheVet than other veterans.

Discussion

Most veterans are willing to access VA information online, although many VA service users do not use My HealtheVet, suggesting more education and research is needed to reduce barriers to its use.

Conclusion

Although adoption of My HealtheVet has been slow, the majority of veterans, including mental health service users, use the internet and indicate a willingness to receive and interact with health information online.     

A rule based solution to co-reference resolution in clinical text

Objective

To build an effective co-reference resolution system tailored to the biomedical domain.

Methods

Experimental materials used in this study were provided by the 2011 i2b2 Natural Language Processing Challenge. The 2011 i2b2 challenge involves co-reference resolution in medical documents. Concept mentions have been annotated in clinical texts, and the mentions that co-refer in each document are linked by co-reference chains. Normally, there are two ways of constructing a system to automatically discoverco-referent links. One is to manually build rules forco-reference resolution; the other is to use machine learning systems to learn automatically from training datasets and then perform the resolution task on testing datasets.

Results

The existing co-reference resolution systems are able to find some of the co-referent links; our rule based system performs well, finding the majority of the co-referent links. Our system achieved 89.6% overall performance on multiple medical datasets.

Conclusions

Manually crafted rules based on observation of training data is a valid way to accomplish high performance in this co-reference resolution task for the critical biomedical domain.