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1.
Objective
To study existing problem list terminologies (PLTs), and to identify a subset of concepts based on standard terminologies that occur frequently in problem list data.Design
Problem list terms and their usage frequencies were collected from large healthcare institutions.Measurement
The pattern of usage of the terms was analyzed. The local terms were mapped to the Unified Medical Language System (UMLS). Based on the mapped UMLS concepts, the degree of overlap between the PLTs was analyzed.Results
Six institutions submitted 76 237 terms and their usage frequencies in 14 million patients. The distribution of usage was highly skewed. On average, 21% of unique terms already covered 95% of usage. The most frequently used 14 395 terms, representing the union of terms that covered 95% of usage in each institution, were exhaustively mapped to the UMLS. 13 261 terms were successfully mapped to 6776 UMLS concepts. Less frequently used terms were generally less ‘mappable’ to the UMLS. The mean pairwise overlap of the PLTs was only 21% (median 19%). Concepts that were shared among institutions were used eight times more often than concepts unique to one institution. A SNOMED Problem List Subset of frequently used problem list concepts was identified.Conclusions
Most of the frequently used problem list terms could be found in standard terminologies. The overlap between existing PLTs was low. The use of the SNOMED Problem List Subset will save developmental effort, reduce variability of PLTs, and enhance interoperability of problem list data. 相似文献2.
Objective
To evaluate non-response rates to follow-up online surveys using a prospective cohort of parents raising at least one child with an autism spectrum disorder. A secondary objective was to investigate predictors of non-response over time.Materials and Methods
Data were collected from a US-based online research database, the Interactive Autism Network (IAN). A total of 19 497 youths, aged 1.9–19 years (mean 9 years, SD 3.94), were included in the present study. Response to three follow-up surveys, solicited from parents after baseline enrollment, served as the outcome measures. Multivariate binary logistic regression models were then used to examine predictors of non-response.Results
31 216 survey instances were examined, of which 8772 or 28.1% were partly or completely responded to. Results from the multivariate model found non-response of baseline surveys (OR 28.0), years since enrollment in the online protocol (OR 2.06), and numerous sociodemographic characteristics were associated with non-response to follow-up surveys (all p<0.05).Discussion
Consistent with the current literature, response rates to online surveys were somewhat low. While many demographic characteristics were associated with non-response, time since registration and participation at baseline played the greatest role in predicting follow-up survey non-response.Conclusion
An important hazard to the generalizability of findings from research is non-response bias; however, little is known about this problem in longitudinal internet-mediated research (IMR). This study sheds new light on important predictors of longitudinal response rates that should be considered before launching a prospective IMR study. 相似文献3.
4.
Schnipper JL Gandhi TK Wald JS Grant RW Poon EG Volk LA Businger A Williams DH Siteman E Buckel L Middleton B 《J Am Med Inform Assoc》2012,19(5):728-734
Objective
To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety.Design
From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating ‘eJournals’ that enabled rapid updating of medication lists during subsequent clinical visits.Measurements
A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies.Results
Among 121 046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04).Conclusions
When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider''s medical record.Trial registration number
This study was registered at ClinicalTrials.gov (NCT00251875). 相似文献5.
Adam Wright Justine Pang Joshua C Feblowitz Francine L Maloney Allison R Wilcox Harley Z Ramelson Louise I Schneider David W Bates 《J Am Med Inform Assoc》2011,18(6):859-867
Background
Accurate knowledge of a patient''s medical problems is critical for clinical decision making, quality measurement, research, billing and clinical decision support. Common structured sources of problem information include the patient problem list and billing data; however, these sources are often inaccurate or incomplete.Objective
To develop and validate methods of automatically inferring patient problems from clinical and billing data, and to provide a knowledge base for inferring problems.Study design and methods
We identified 17 target conditions and designed and validated a set of rules for identifying patient problems based on medications, laboratory results, billing codes, and vital signs. A panel of physicians provided input on a preliminary set of rules. Based on this input, we tested candidate rules on a sample of 100 000 patient records to assess their performance compared to gold standard manual chart review. The physician panel selected a final rule for each condition, which was validated on an independent sample of 100 000 records to assess its accuracy.Results
Seventeen rules were developed for inferring patient problems. Analysis using a validation set of 100 000 randomly selected patients showed high sensitivity (range: 62.8–100.0%) and positive predictive value (range: 79.8–99.6%) for most rules. Overall, the inference rules performed better than using either the problem list or billing data alone.Conclusion
We developed and validated a set of rules for inferring patient problems. These rules have a variety of applications, including clinical decision support, care improvement, augmentation of the problem list, and identification of patients for research cohorts. 相似文献6.
Objective
To introduce the availability of grant-to-article linkage data associated with National Institutes of Health (NIH) grants and to perform a high-level analysis of the publication outputs and impacts associated with those grants.Design
Articles were linked to the grants they acknowledge using the grant acknowledgment strings in PubMed using a parsing and matching process as embodied in the NIH Scientific Publication Information Retrieval & Evaluation System system. Additional data from PubMed and citation counts from Scopus were added to the linkage data. The data comprise 2 572 576 records from 1980 to 2009.Results
The data show that synergies between NIH institutes are increasing over time; 29% of current articles acknowledge grants from multiple institutes. The median time lag to publication for a new grant is 3 years. Each grant contributes to approximately 1.7 articles per year, averaged over all grant types. Articles acknowledging US Public Health Service (PHS, which includes NIH) funding are cited twice as much as US-authored articles acknowledging no funding source. Articles acknowledging both PHS funding and a non-US government funding source receive on average 40% more citations that those acknowledging PHS funding sources alone.Conclusion
The US PHS is effective at funding research with a higher-than-average impact. The data are amenable to further and much more detailed analysis. 相似文献7.
Wright A Pang J Feblowitz JC Maloney FL Wilcox AR McLoughlin KS Ramelson H Schneider L Bates DW 《J Am Med Inform Assoc》2012,19(4):555-561
Background
Accurate clinical problem lists are critical for patient care, clinical decision support, population reporting, quality improvement, and research. However, problem lists are often incomplete or out of date.Objective
To determine whether a clinical alerting system, which uses inference rules to notify providers of undocumented problems, improves problem list documentation.Study Design and Methods
Inference rules for 17 conditions were constructed and an electronic health record-based intervention was evaluated to improve problem documentation. A cluster randomized trial was conducted of 11 participating clinics affiliated with a large academic medical center, totaling 28 primary care clinical areas, with 14 receiving the intervention and 14 as controls. The intervention was a clinical alert directed to the provider that suggested adding a problem to the electronic problem list based on inference rules. The primary outcome measure was acceptance of the alert. The number of study problems added in each arm as a pre-specified secondary outcome was also assessed. Data were collected during 6-month pre-intervention (11/2009–5/2010) and intervention (5/2010–11/2010) periods.Results
17 043 alerts were presented, of which 41.1% were accepted. In the intervention arm, providers documented significantly more study problems (adjusted OR=3.4, p<0.001), with an absolute difference of 6277 additional problems. In the intervention group, 70.4% of all study problems were added via the problem list alerts. Significant increases in problem notation were observed for 13 of 17 conditions.Conclusion
Problem inference alerts significantly increase notation of important patient problems in primary care, which in turn has the potential to facilitate quality improvement.Trial Registration
ClinicalTrials.gov: NCT01105923. 相似文献8.
Joshua R Vest Hongwei Zhao 'Jon Jaspserson Larry D Gamm Robert L Ohsfeldt 《J Am Med Inform Assoc》2011,18(2):143-149
Objective
Health information exchange (HIE) is the process of electronically sharing patient-level information between providers. However, where implemented, reports indicate HIE system usage is low. The aim of this study was to determine the factors associated with different types of HIE usage.Design
Cross-sectional analysis of clinical data from emergency room encounters included in an operational HIE effort linked to system user logs using crossed random-intercept logistic regression.Measurements
Independent variables included factors indicative of information needs. System usage was measured as none, basic usage, or a novel pattern of usage.Results
The system was accessed for 2.3% of all encounters (6142 out of 271 305). Novel usage patterns were more likely for more complex patients. The odds of HIE usage were lower in the face of time constraints. In contrast to expectations, system usage was lower when the patient was unfamiliar to the facility.Limitations
Because of differences between HIE efforts and the fact that not all types of HIE usage (ie, public health) could be included in the analysis, results are limited in terms of generalizablity.Conclusions
This study of actual HIE system usage identifies patients and circumstances in which HIE is more likely to be used and factors that are likely to discourage usage. The paper explores the implications of the findings for system redesign, information integration across exchange partners, and for meaningful usage criteria emerging from provisions of the Health Information Technology for Economic & Clinical Health Act. 相似文献9.
Objective
To develop a system to extract follow-up information from radiology reports. The method may be used as a component in a system which automatically generates follow-up information in a timely fashion.Methods
A novel method of combining an LSP (labeled sequential pattern) classifier with a CRF (conditional random field) recognizer was devised. The LSP classifier filters out irrelevant sentences, while the CRF recognizer extracts follow-up and time phrases from candidate sentences presented by the LSP classifier.Measurements
The standard performance metrics of precision (P), recall (R), and F measure (F) in the exact and inexact matching settings were used for evaluation.Results
Four experiments conducted using 20 000 radiology reports showed that the CRF recognizer achieved high performance without time-consuming feature engineering and that the LSP classifier further improved the performance of the CRF recognizer. The performance of the current system is P=0.90, R=0.86, F=0.88 in the exact matching setting and P=0.98, R=0.93, F=0.95 in the inexact matching setting.Conclusion
The experiments demonstrate that the system performs far better than a baseline rule-based system and is worth considering for deployment trials in an alert generation system. The LSP classifier successfully compensated for the inherent weakness of CRF, that is, its inability to use global information. 相似文献10.
K M Augestad G Berntsen K Lassen J G Bellika R Wootton R O Lindsetmo Study Group of Research Quality in Medical Informatics Decision Support 《J Am Med Inform Assoc》2012,19(1):13-21
Introduction
The Consolidated Standards for Reporting Trials (CONSORT) were published to standardize reporting and improve the quality of clinical trials. The objective of this study is to assess CONSORT adherence in randomized clinical trials (RCT) of disease specific clinical decision support (CDS).Methods
A systematic search was conducted of the Medline, EMBASE, and Cochrane databases. RCTs on CDS were assessed against CONSORT guidelines and the Jadad score.Result
32 of 3784 papers identified in the primary search were included in the final review. 181 702 patients and 7315 physicians participated in the selected trials. Most trials were performed in primary care (22), including 897 general practitioner offices. RCTs assessing CDS for asthma (4), diabetes (4), and hyperlipidemia (3) were the most common. Thirteen CDS systems (40%) were implemented in electronic medical records, and 14 (43%) provided automatic alerts. CONSORT and Jadad scores were generally low; the mean CONSORT score was 30.75 (95% CI 27.0 to 34.5), median score 32, range 21–38. Fourteen trials (43%) did not clearly define the study objective, and 11 studies (34%) did not include a sample size calculation. Outcome measures were adequately identified and defined in 23 (71%) trials; adverse events or side effects were not reported in 20 trials (62%). Thirteen trials (40%) were of superior quality according to the Jadad score (≥3 points). Six trials (18%) reported on long-term implementation of CDS.Conclusion
The overall quality of reporting RCTs was low. There is a need to develop standards for reporting RCTs in medical informatics. 相似文献11.
Wagholikar KB Maclaughlin KL Henry MR Greenes RA Hankey RA Liu H Chaudhry R 《J Am Med Inform Assoc》2012,19(5):833-839
Objective
To develop a computerized clinical decision support system (CDSS) for cervical cancer screening that can interpret free-text Papanicolaou (Pap) reports.Materials and Methods
The CDSS was constituted by two rulebases: the free-text rulebase for interpreting Pap reports and a guideline rulebase. The free-text rulebase was developed by analyzing a corpus of 49 293 Pap reports. The guideline rulebase was constructed using national cervical cancer screening guidelines. The CDSS accesses the electronic medical record (EMR) system to generate patient-specific recommendations. For evaluation, the screening recommendations made by the CDSS for 74 patients were reviewed by a physician.Results and Discussion
Evaluation revealed that the CDSS outputs the optimal screening recommendations for 73 out of 74 test patients and it identified two cases for gynecology referral that were missed by the physician. The CDSS aided the physician to amend recommendations in six cases. The failure case was because human papillomavirus (HPV) testing was sometimes performed separately from the Pap test and these results were reported by a laboratory system that was not queried by the CDSS. Subsequently, the CDSS was upgraded to look up the HPV results missed earlier and it generated the optimal recommendations for all 74 test cases.Limitations
Single institution and single expert study.Conclusion
An accurate CDSS system could be constructed for cervical cancer screening given the standardized reporting of Pap tests and the availability of explicit guidelines. Overall, the study demonstrates that free text in the EMR can be effectively utilized through natural language processing to develop clinical decision support tools. 相似文献12.
Objective
Relation extraction in biomedical text mining systems has largely focused on identifying clause-level relations, but increasing sophistication demands the recognition of relations at discourse level. A first step in identifying discourse relations involves the detection of discourse connectives: words or phrases used in text to express discourse relations. In this study supervised machine-learning approaches were developed and evaluated for automatically identifying discourse connectives in biomedical text.Materials and Methods
Two supervised machine-learning models (support vector machines and conditional random fields) were explored for identifying discourse connectives in biomedical literature. In-domain supervised machine-learning classifiers were trained on the Biomedical Discourse Relation Bank, an annotated corpus of discourse relations over 24 full-text biomedical articles (∼112 000 word tokens), a subset of the GENIA corpus. Novel domain adaptation techniques were also explored to leverage the larger open-domain Penn Discourse Treebank (∼1 million word tokens). The models were evaluated using the standard evaluation metrics of precision, recall and F1 scores.Results and Conclusion
Supervised machine-learning approaches can automatically identify discourse connectives in biomedical text, and the novel domain adaptation techniques yielded the best performance: 0.761 F1 score. A demonstration version of the fully implemented classifier BioConn is available at: http://bioconn.askhermes.org. 相似文献13.
14.
Zach Landis Lewis Claudia Mello-Thoms Oliver J Gadabu E Miranda Gillespie Gerald P Douglas Rebecca S Crowley 《J Am Med Inform Assoc》2011,18(6):868-874
Objective
To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi.Materials and methods
We evaluated recommendations from Malawi''s ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure''s denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups.Results
We analyzed 423 831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi''s ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled.Discussion
It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs'' opportunities to reflect on their performance.Conclusion
A moderate number of recommendations from Malawi''s ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings. 相似文献15.
Sivakumar R Wellsted D Parker K Lynch M Ghosh P Khan SA 《Postgraduate medical journal》2006,82(965):220-223
Objective
To evaluate the utility of N terminal pro brain natriuretic peptide (NT‐proBNP) as a diagnostic marker for diastolic dysfunction or failure, systolic dysfunction, and significant valve disorders in patients over 75 years.Design
Cohort study.Setting
Outpatient echocardiography service in a district general hospital.Participants
100 consecutive patients.Main outcome measures
Sensitivity, specificity, positive predictive values, negative predictive values, and area under receiver operating characteristic curve for NT‐proBNP assay in the diagnosis of left ventricular diastolic dysfunction or failure, systolic dysfunction, and significant valve disorders.Results
For diagnosis of systolic dysfunction NT‐proBNP level of 424 pg/ml had a sensitivity of 96%, specificity of 45%, positive predictive value of 36%, and negative predictive value of 96%. The area under the curve was 0.71 (95% confidence intervals: 0.69 to 0.89). In valve heart disease, level of 227 pg/ml had sensitivity of 91%, specificity of 43%, positive predictive value of 40%, and negative predictive value of 92%. Patients with diastolic dysfunction/failure had lower plasma concentrations.Conclusions
This study showed that NT‐proBNP had excellent negative predictive value for systolic dysfunction and significant valve disorders in very elderly patients. It increased significantly in systolic dysfunction, valve heart disease, and atrial fibrillation. NT‐proBNP is not useful in the diagnosis of diastolic dysfunction or diastolic heart failure using standard echocardiography criteria. 相似文献16.
Objectives
To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes.Design
Interrupted time series analysis, 2003–2009.Setting
A large US not-for-profit integrated health care organization.Participants
29 hospitals in Northern and Southern California.Intervention
An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools.Main outcome measures
Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures).Results
EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; −3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient −0.76, 95% CI −1.37 to −0.16) but no decrease in fall rates (−0.091; −0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (−0.16; −0.20 to −0.13), while fall rates did not (0.0052; −0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72).Conclusions
The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored. 相似文献17.
Background
Laparoscopic surgery has changed the face of medical care forever. The benefits of laparoscopic open surgery have been demonstrated in virtually all major abdominal surgical procedures. Laparoscopy has introduced a new skill set that must be mastered and requires dedicated training. The teaching of laparoscopic operative skills in the clinical setting is constrained by the complexity of procedures, medicolegal and ethical concerns, fiscal and time limitations. This has created the need for formal training outside the operating room. Simulator-based training holds great promise in enhancing surgical education and providing a safe, cost-effective means for practicing techniques prior to their use in the operating room.Methods
The surgical residents of two batches were recruited for the study. The residents were randomized to either a group that received training on a simulator or a controlled group that did not receive the training or to a group that received training twice.Result
The residents who received training on a simulator demonstrated better psychomotor skills in the operation theatre than those who did not. Training in simulator environment can contribute to the development of technical skills relevant to the performance of laparoscopic surgery in vivo. Training at regular intervals will benefit the residents in gaining significant improvement of their psychomotor skills.Conclusion
Laparoscopic trainer is a promising tool for training in laparoscopic surgery.Key Words: Laparoscopic simulator, Endotrainer, Training, Laparoscopic surgery 相似文献18.
Objective
To examine the 21 month clinical outcome and bleeding complications in hospital survivors with non‐ST segment elevation acute coronary syndromes (NSTEACS) who were discharged with combined clopidogrel and aspirin anti‐thrombotic therapy, and compare with those having ST segment elevation myocardial infarction (STEMI) who were discharged with aspirin alone.Design
Observational study.Setting
A large university hospital.Patients
224 patients were admitted to hospital with either NSTEACS or STEMI, and survived to discharge between 1 October 2001 and 31 December 2002.Main outcome measures
Cardiovascular death, total death, new myocardial infarction, unstable angina requiring hospitalisation, stroke or transient ischaemic attack, coronary revascularisation; and fatal, life threatening, major and minor bleeding over 21 months after discharge.Results
Despite having no or small infarct (median maximum creatine kinase 155 v 1295 u/l; p<0.001) and taking more antianginal drugs, patients with NSTEACS had similar rates of cardiovascular death (9.5% v 8.3%; p = NS), new myocardial infarction (9.5% v 6.5%; p = NS) or unstable angina requiring hospitalisation (15.5% v 10.2%; p = NS) when compared with STEMI. Fatal, life threatening or major bleeding were <1% in both groups (p = NS); and minor bleeding occurred in 4.3% NSTEACS and 2.8% STEMI patients respectively (p = NS).Conclusions
Patients with NSTEACS had a similar and unfavourable long term outcome when compared with STEMI. There was no difference in serious bleeding complications between both groups. 相似文献19.
Objective
High tibial osteotomy (HTO) is one treatment option for young and active patients with unicompartmental osteoarthritis. The success of this procedure substantially depends on the degree of correction of the mechanical axis. Computer-assisted navigation systems are believed to improve the precision of axis correction through intraoperative real-time monitoring. This study investigates the accuracy of limb alignment measurements with a navigation system on a cadaver specimen.Materials and methods
The measurements were performed on a well-preserved cadaver specimen with a mechanical leg axis of 4° varus. Data was collected during the HTO workflow. Repeated serial measurements were undertaken by four different surgeons. After these measurements, different landmarks were deliberately set at the wrong place to examine the influence of mistakes during registration.Results
There was a high intra-and interobserver reliability with a mean mechanical leg axis of 3.9° ± 0.7° and a mean error of 0.6°. The grossly incorrect placement of landmarks for knee and ankle center resulted in an incorrect mechanical leg axis of 1° valgus up to 10° varus.Conclusion
The computer-assisted navigation system provided precise information about the mechanical leg axis, irrespective of the observer''s experience. 相似文献20.
Jing-song Li Tian-shu Zhou Jian Chu Kenji Araki Hiroyuki Yoshihara 《J Am Med Inform Assoc》2011,18(5):683-689