听骨链CT仿真内窥镜的临床应用

目的　探讨听骨链CT仿真内窥镜 (CTVE)的临床应用价值及其限度。方法　使用准直 1 0mm、螺距 1 0扫描 ,骨算法、视野 9 6cm、间隔 0 1- 0 2mm重建对 4 0例临床怀疑中耳病变(30例手术 )的患者进行CTVE成像 ,并与轴位高分辨率CT(HRCT)、多平面重组 (MPR)图像及手术结果进行对照分析。结果　CTVE诊断听小骨破坏的准确性为 92 6% ,明显高于轴位HRCT(84 % )和MPR(77% )图像。CTVE也能清楚地显示听骨链发育异常和术后的状况。结论　CTVE能显示听骨链的立体影像 ,有利于听骨链病变的显示和诊断。但CTVE不能清楚地显示鼓室腔内异常软组织、鼓膜和鼓室骨壁的异常改变 ,且结果易受人为因素影响。     

Accuracy of a computerized clinical decision-support system for asthma assessment and management

Objective

To evaluate the accuracy of a computerized clinical decision-support system (CDSS) designed to support assessment and management of pediatric asthma in a subspecialty clinic.

Design

Cohort study of all asthma visits to pediatric pulmonology from January to December, 2009.

Measurements

CDSS and physician assessments of asthma severity, control, and treatment step.

Results

Both the clinician and the computerized CDSS generated assessments of asthma control in 767/1032 (74.3%) return patients, assessments of asthma severity in 100/167 (59.9%) new patients, and recommendations for treatment step in 66/167 (39.5%) new patients. Clinicians agreed with the CDSS in 543/767 (70.8%) of control assessments, 37/100 (37%) of severity assessments, and 19/66 (29%) of step recommendations. External review classified 72% of control disagreements (21% of all control assessments), 56% of severity disagreements (37% of all severity assessments), and 76% of step disagreements (54% of all step recommendations) as CDSS errors. The remaining disagreements resulted from pulmonologist error or ambiguous guidelines. Many CDSS flaws, such as attributing all ‘cough’ to asthma, were easily remediable. Pediatric pulmonologists failed to follow guidelines in 8% of return visits and 18% of new visits.

Limitations

The authors relied on chart notes to determine clinical reasoning. Physicians may have changed their assessments after seeing CDSS recommendations.

Conclusions

A computerized CDSS performed relatively accurately compared to clinicians for assessment of asthma control but was inaccurate for treatment. Pediatric pulmonologists failed to follow guideline-based care in a small proportion of patients.     

Evaluation of family history information within clinical documents and adequacy of HL7 clinical statement and clinical genomics family history models for its representation: a case report

Family history information has emerged as an increasingly important tool for clinical care and research. While recent standards provide for structured entry of family history, many clinicians record family history data in text. The authors sought to characterize family history information within clinical documents to assess the adequacy of existing models and create a more comprehensive model for its representation. Models were evaluated on 100 documents containing 238 sentences and 410 statements relevant to family history. Most statements were of family member plus disease or of disease only. Statement coverage was 91%, 77%, and 95% for HL7 Clinical Genomics Family History Model, HL7 Clinical Statement Model, and the newly created Merged Family History Model, respectively. Negation (18%) and inexact family member specification (9.5%) occurred commonly. Overall, both HL7 models could represent most family history statements in clinical reports; however, refinements are needed to represent the full breadth of family history data.     

Adult immunization: the medical record design as a facilitator for physician compliance

A three-year prospective chart audit of a family practice residency program was performed to measure physician compliance in following the recommendations of an adult immunization program. Despite curriculum changes, performance self-evaluation, and reminders by faculty members to residents about the need for adult immunization, physician compliance was poor in the second year of the study. It was thought that components of the medical record might be improved to facilitate physician compliance in the adult immunization program. At the beginning of the third year of the audit, tetanus and pneumococcal vaccines were preprinted on the health maintenance inventory (HMI), but influenza was not. The chart design also was changed to put the HMI in a more prominent place. In the third year of the audit, physician compliance with tetanus and pneumococcus immunization improved significantly. The results of the chart review suggest that physician compliance with adult immunization programs can be improved with appropriate chart design.     

病案首页病人基本信息常见问题分析及对策

目的 为提高病案首页质量,更好地为住院患者服务.方法 对2012年5-6月3 205份病案首页基本信息存在问题进行统计分析.结果 分析原因有四方面：（1）病人提供信息有误;（2）工作人员责任心欠缺;（3）医保卡信息有误;（4）制度不完善.针对以上问题实施相应对策后对2012年9-10月3 530份病案首页缺陷率进行对照.缺陷率自12.9％下降到2％,差异有显著性（P＜0.01）.结论 通过加强与患者沟通、提供人性化服务、完善相关制度、强化医务人员工作责任心,可以提高病案首页质量,从而提高服务质量.     

关于电子病历法律效力及应用的思考

电子病历是医疗机构信息化发展的重要组成部分?电子病历的法律效力对于电子病历的推广与应用有深远影响?文章分析了电子病历作为证据的法律效力以及电子病历在实际应用中出现的部分与法律相关的问题,并阐述其推广的重要意义?     

云南某受援医院儿科住院患者7年病案数据特征及医疗帮扶需求分析

 目的 调研云南省绿春县人民医院儿科病房7年住院病例数据,分析该医院儿科帮扶需求。方法 抽取该县人民医院儿科病房2013年1月至2019年12月出院的所有患儿的归档病案信息,以出院患儿的第一诊断进行病种的统计,疾病分类按照国际疾病分类（ICD-10）标准,分析主要住院病种特点和变化情况、主要病种的临床特点、住院费用的变化。结果 2013—2019年该儿科病房出院患儿共计14 934人次,出院患儿人次数呈逐年增加趋势。排在前十位的病种分别为支气管肺炎、急性上呼吸道感染、急性支气管炎、急性胃肠炎、新生儿窒息、黄疸、早产儿、疱疹性咽峡炎、惊厥、急性咽炎。住院患儿的平均年龄（22.7±32.8）个月,以婴幼儿为主;哈尼族占比91.0%;总体住院费用的中位数略提高,从2013年的1 841.0元（95% CI：2 237.9~2 453.8）提高到2019年的2 045.6元（95% CI：2 525.4~2 716.9）（P<0.05）;其中检查费用的中位数从2013年的156.0元（95% CI：349.5~419.7）下降至2019年的143.9元（95% CI：210.0~229.8）（P<0.05）;儿科病房的转诊率为2.2%,死亡率为0.3%。结论 通过调研受援医院儿科病房出院患者的医疗信息,充分评估受援医院的疾病谱、医疗就诊情况等,精准地为受援医院提供医疗服务,以便于更好地完成乡村振兴计划。     

Research and applications: Word sense disambiguation in the clinical domain: a comparison of knowledge-rich and knowledge-poor unsupervised methods

Objective

To evaluate state-of-the-art unsupervised methods on the word sense disambiguation (WSD) task in the clinical domain. In particular, to compare graph-based approaches relying on a clinical knowledge base with bottom-up topic-modeling-based approaches. We investigate several enhancements to the topic-modeling techniques that use domain-specific knowledge sources.

Materials and methods

The graph-based methods use variations of PageRank and distance-based similarity metrics, operating over the Unified Medical Language System (UMLS). Topic-modeling methods use unlabeled data from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC II) database to derive models for each ambiguous word. We investigate the impact of using different linguistic features for topic models, including UMLS-based and syntactic features. We use a sense-tagged clinical dataset from the Mayo Clinic for evaluation.

Results

The topic-modeling methods achieve 66.9% accuracy on a subset of the Mayo Clinic''s data, while the graph-based methods only reach the 40–50% range, with a most-frequent-sense baseline of 56.5%. Features derived from the UMLS semantic type and concept hierarchies do not produce a gain over bag-of-words features in the topic models, but identifying phrases from UMLS and using syntax does help.

Discussion

Although topic models outperform graph-based methods, semantic features derived from the UMLS prove too noisy to improve performance beyond bag-of-words.

Conclusions

Topic modeling for WSD provides superior results in the clinical domain; however, integration of knowledge remains to be effectively exploited.     

On the use of statistics for representing the knowledge acquired from experts in a medical consulting system

For making medical consulting systems, it is important and significant to select and devise the method for representing the knowledge acquired from professional experts. As quantities of data required for consultation are increasing according to the progress of medical science, we have to introduce some new kinds of statistics into a medical consultation system. From another point of view, since the process of diagnosis of experts is considered to be a kind of effective model for compressing (or condensing) data quantitatively and qualitatively, we discuss the use of statistics for representing the knowledge acquired from experts from the standpoint of data compression.     

The impact of the electronic medical record on structure,process, and outcomes within primary care: a systematic review of the evidence

Background

The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations.

Objective

The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices.

Materials and methods

Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria.

Results and discussion

The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedian''s framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.     

NHMRC grant applications: a comparison of "track record" scores allocated by grant assessors with bibliometric analysis of publications

OBJECTIVES: To investigate the correlation between the publication "track record" score of applicants for National Health and Medical Research Council (NHMRC) project grants and bibliometric measures of the same publication output; and to compare the publication outputs of recipients of NHMRC program grants with those of recipients under other NHMRC grant schemes. DESIGN: For a 15% random sample of 2000 and 2001 project grant applications, applicants' publication track record scores (assigned by grant assessors) were compared with bibliometric data relating to publications issued in the previous 6 years. Bibliometric measures included total publications, total citations, and citations per publication. The program grants scheme underwent a major revision in 2001 to better support broadly based collaborative research programs. For all successful 2001 and 2002 program grant applications, a citation analysis was undertaken, and the results were compared with citation data on NHMRC grant recipients from other funding schemes. MAIN OUTCOME MEASURE: Correlation between publication track record scores and bibliometric indicators. RESULTS: The correlation between mean project-grant track record scores and all bibliometric indicators was poor and below statistically significant levels. Recipients of program grants had a strong citation record compared with recipients under other NHMRC funding schemes. CONCLUSION: The poor correlation between track record scores and bibliometric measures for project grant applications suggests that factors other than publication history may influence the assignment of track record scores.     

Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings

Objective

To synthesize the literature on clinical decision-support systems'' (CDSS) impact on healthcare practitioner performance and patient outcomes.

Design

Literature search on Medline, Embase, Inspec, Cinahl, Cochrane/Dare and analysis of high-quality systematic reviews (SRs) on CDSS in hospital settings. Two-stage inclusion procedure: (1) selection of publications on predefined inclusion criteria; (2) independent methodological assessment of preincluded SRs by the 11-item measurement tool, AMSTAR. Inclusion of SRs with AMSTAR score 9 or above. SRs were thereafter rated on level of evidence. Each stage was performed by two independent reviewers.

Results

17 out of 35 preincluded SRs were of high methodological quality and further analyzed. Evidence that CDSS significantly impacted practitioner performance was found in 52 out of 91 unique studies of the 16 SRs examining this effect (57%). Only 25 out of 82 unique studies of the 16 SRs reported evidence that CDSS positively impacted patient outcomes (30%).

Conclusions

Few studies have found any benefits on patient outcomes, though many of these have been too small in sample size or too short in time to reveal clinically important effects. There is significant evidence that CDSS can positively impact healthcare providers'' performance with drug ordering and preventive care reminder systems as most clear examples. These outcomes may be explained by the fact that these types of CDSS require a minimum of patient data that are largely available before the advice is (to be) generated: at the time clinicians make the decisions.     

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.     

电子病案结构和临床辅助决策系统设计

目的建立肿瘤医院电子病案的临床辅助决策系统和其他业务分析工具。方法分析肿瘤疾病和治疗过程的特点,以及临床业务分析的需要,提出与“病人一住院次”平行的“病人一治疗次”电子病案结构,设计实现这种双重结构的病历书写模版。结果在此结构基础上利用数据仓库工具建立临床辅助决策演示系统,包括治疗路径决策和治疗方案决策。结论建立临床辅助决策系统的关键是电子病案提供符合临床逻辑的结构和数据。     

基于集成平台和HL7标准的危急值系统设计与实现

详细阐述基于集成平台和HL7信息交换标准的危急值系统架构、HL7消息总体设计,指出该系统具有降低院内系统耦合、加强医疗信息联通共享等优点,具有较高的应用价值。