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Frénot, S., and F. Laforest. "Medical Record Management Systems: Criticisms and New Perspectives." Methods of Information in Medicine 38, no. 02 (1999): 89–95. http://dx.doi.org/10.1055/s-0038-1634179.
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AbstractThe first generation of computerized medical records stored the data as text, but these records did not bring any improvement in information manipulation. The use of a relational database management system (DBMS) has largely solved this problem as it allows for data requests by using SQL. However, this requires data structuring which is not very appropriate to medicine. Moreover, the use of templates and icon user interfaces has introduced a deviation from the paper-based record (still existing). The arrival of hypertext user interfaces has proven to be of interest to fill the gap between the paper-based medical record and its electronic version. We think that further improvement can be accomplished by using a fully document-based system. We present the architecture, advantages and disadvantages of classical DBMS-based and Web/DBMS-based solutions. We also present a document-based solution and explain its advantages, which include communication, security, flexibility and genericity.
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Baratov, Dilshod, and Elmurod Astanaliev. "Developing a new monitoring mechanism of electronic document management of technical documentation for railway automation." E3S Web of Conferences 264 (2021): 05018. http://dx.doi.org/10.1051/e3sconf/202126405018.
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The methods of creating automation tools in the general and analytical process and improving their efficiency are carried out in terms of brief comments on construction and creation and improving their efficiency. Electronic record keeping systems are considered. The creation of automated electronic document management systems and a comparative analysis of these processes are presented. Methods of analysis, synthesis and study of technical documentation electronic document flow are formalized. A graphical model of the electronic document management of technical documents is synthesized. The developed model considers the division of document flows into a set of participants, processes and situations. It is recommended to use a set of matrices to determine the form of presentation of the workflow of technical documentation. Based on the apparatus of graph theory, a method of creating an electronic document management model of technical documents are developed.
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Jatin Pahuja and Dr. Neha Agrawal. "Record Storage and Management System Using Blockchain." November 2020 6, no. 11 (November 23, 2020): 72–78. http://dx.doi.org/10.46501/ijmtst061113.
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On a daily basis we deal with documents like educational records, health records, certificates etc. Medical records are still being stored on legacy systems which carries the risk of losing important documents. There are security and privacy concerns regarding the safety of documents on centralized server. To overcome these difficulties, we made a blockchain based record storage web app through which anyone upload their medical records on the blockchain and can access them with a private key. The patient or the user can download and access reports from anywhere and can also manage to share them with his doctor etc. Blockchain is a decentralized, distributed, peer to peer ledger on the internet. Blockchain technology helps to maintain security and reliability without placing any trust in a third party. The use of smart contracts in blockchain helps in making things much easier. This paper examines the record storage system including the technologies involved and the methodologies. The approach used for making an electronic health record storage web app through which we can implement a more broader record storage system that can store and manage numerous types of records.
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Kartini, Kartini, Sukaesih Sukaesih, and Agung Budiono. "Kinerja pengelolaan arsip Kantor Pelayanan Utama Bea dan Cukai Tipe A Tanjung Priok." Jurnal Kajian Informasi & Perpustakaan 7, no. 2 (December 28, 2019): 175. http://dx.doi.org/10.24198/jkip.v7i2.21250.
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The dynamic records management of goods import notification documents is an essential activity in storing data on goods entering Indonesia. The Main Service Office for Customs and Excise Type A Tanjung Priok as a government agency is obliged to record incoming goods as trade data. This study aimed to determine the dynamic records management of imported goods notification (PIB) documents on customs activities for the success of dwelling time at the Main Service Office for Customs and Excise Type A Tanjung Priok. The research method used a case study through a qualitative approach. Data collection techniques used were observation, interviews, and document study. The results showed the process of recording imported goods document notifications through the process of creating and receiving import documents began from the delivery of imported goods document notification (PIB) to the Customs Office. Submitting of the notifications was through the Electronic Data Exchange (PDE) system to the determination of the document path for 4 minutes. The organization process of notification documents for imported goods goes through 5 stages, namely, distribution of documents, the process of completing customs administration of imported goods documents, storing the processed documents, rediscovering documents, and maintaining imported goods documents. The process of dissemination at the Customs and Excise agency itself is inseparable from a system called Customs-Excise Integrated System and Automation (CEISA). The system is an integrated system of all Directorate General Customs and Excise services to all public service users. Their can access this system without limited space and place.
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KAWAKAMI, Takahiro, Katsuhiko NAGASE, Yuko YOKOI, Yoshimichi SAI, and Toshinori MURAYAMA. "Improvement of Informed Consent Document Management in Clinical Trials Using an Electronic Medical Record System." Rinsho yakuri/Japanese Journal of Clinical Pharmacology and Therapeutics 50, no. 3 (May 31, 2019): 81–86. http://dx.doi.org/10.3999/jscpt.50.81.
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Paterson, Mary, Alison McAulay, and Brian McKinstry. "Integrating third-party telehealth records with the general practice electronic medical record system: a solution." Journal of Innovation in Health Informatics 24, no. 4 (November 17, 2017): 317. http://dx.doi.org/10.14236/jhi.v24i4.915.
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Background: The implementation of telemonitoring at scale has been less successful than anticipated, often hindered by clinicians’ perceived increase in workload. One important factor has been the lack of integration of patient generated data (PGD) with the electronic medical record (EMR). Clinicians have had problems accessing PGD on telehealth systems especially in patient consultations in primary care.Objective: To design a method to produce a report of PGD that is available to clinicians through their routine EMR system.Method: We modelled a system with a use case approach using Unified Modelling Language to enable us to design a method of producing the required report. Anonymised PGD are downloaded from a third-party telehealth system to National Health Service (NHS) systems and linked to the patient record available in the hospital recording system using the patient NHS ID through an interface accessed by healthcare professionals. The telehealth data are then processed into a report using the patient record. This report summarises the readings in graphical and tabular form with an average calculated and with a recommended follow-up suggested if required. The report is then disseminated to general practitioner practices through routine document distribution pathways.Results: This addition to the telehealth system is viewed positively by clinicians. It has helped to greatly increase the number of general practices using telemonitoring to manage blood pressure in NHS Lothian.
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Su, Shaosheng, Yaocheng Yang, Yuanyuan He, Yong Yang, Shujuan Zhang, and Minting Cheng. "Design and Application of Document Management System of Electronic Medical Records." Chinese Medical Record English Edition 1, no. 12 (December 2013): 514–17. http://dx.doi.org/10.3109/23256176.2013.881030.
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Tali, Dmitry, and Oleg Finko. "Cryptographic Recursive Control of Integrity of Metadata Electronic Documents. Part 3. Application Methodology." Voprosy kiberbezopasnosti, no. 1(41) (2021): 57–68. http://dx.doi.org/10.21681/2311-3456-2021-1-57-68.
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The purpose of the study is to develop recommendations for organizing a cryptographic recursive 2-D control of the integrity of electronic documents metadata based on chain data recording technology. Research methods: the proposed methodology is based on the general principles of constructing a chain data record, which is a dynamic registry, where changes in metadata records are allowed without changing the previously entered information. In this case, the relationship between the metadata records is ensured through the use of a cryptographic hash function. Research result: the analysis of the life cycle of electronic documents processed by automated information systems of electronic document management was carried out, based on the results of which it was concluded that it is necessary to protect metadata by cryptographic methods in order to control their integrity and effectively manage electronic documents. The technique of cryptographic recursive 2-D control of the integrity of metadata of electronic documents, based on the previously proposed by the authors a mathematical model and a set of algorithms, has been developed. General and particular results of its application are described. The practical use of the proposed solutions makes it possible to provide the necessary measures to protect electronic documents in a time-changing environment, in accordance with the requirements for document management. This effect is achieved by bringing the existing metadata structure to the form of a multidimensional model, thereby making it possible to achieve the required level of their security
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Pandya, Chintan, Sandra Sabatka, Michelle Kettinger, Alexander Alongi, Lauren M. Hamel, Elizabeth A. Guancial, and David W. Dougherty. "Using electronic medical record system to improve compliance with national guidelines for comprehensive distress screening in cancer patients." Journal of Clinical Oncology 36, no. 30_suppl (October 20, 2018): 309. http://dx.doi.org/10.1200/jco.2018.36.30_suppl.309.
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309 Background: Psychosocial distress screening (DS) and management is associated with improved quality of life and outcomes in cancer patients and is required for accreditation by the American College of Surgeons Commission on Cancer. Comprehensive distress screening (CDS) consists of routine distress screening, evaluation, referral to appropriate psychosocial services, and follow-up to ensure adequate care. Electronic medical record (EMR) systems can be leveraged to facilitate and document CDS as part of clinical care and to evaluate the CDS process as a quality standard. The aim of this study is to develop and implement an EMR-based tool to document and evaluate the CDS process as part of routine oncology care. Methods: An EMR-based tool with structured data fields is developed for social workers to document risk factors for distress, assessment, management plan including psychosocial service referrals, and time spent delivering care following DS using the NCCN distress thermometer (DT). Evaluation of CDS process is done in cancer patients who have documented psychosocial care in the EMR-system from 1/2017-5/2018. Results: During the study period, 1327 cancer patients underwent 2480 distress screening evaluations. The average distress score was 3.2 (median = 2) on the DT scale of 0-10, with 855 (64%), 326 (25%), and 146 (11%) patients reporting on average mild (0-3), moderate (4-6), and severe (7-10) distress respectively. 400/1327 (30%) patients accounted for 1177 documented social work contact/visits, of which financial (40%) and emotional (15%) were the most common concerns. 89% (1047) of the visits had follow-up plans and 77% of encounters resulted in referrals, of which financial support (26%) and pharmacy assistance (22%) were the most common referral services. The average time spent on each psychosocial care visit was reported to be 21 minutes. Conclusions: EMR-based forms with structured data fields can be used to document and promote improved adherence to national guidelines for CDS as part of routine oncology care by facilitating data collection. Such tools can be leveraged to capture relevant data on impact of CDS on social work resource utilization.
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Alam, Mehnaaz, D. Yamini Sai Nikitha, Sai Sugun Jala, and Gulam Khaleel Ahmed. "Archival and management of clinical trial documents." International Journal of Clinical Trials 8, no. 1 (January 22, 2021): 101. http://dx.doi.org/10.18203/2349-3259.ijct20210150.
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<p class="abstract">Clinical trial documents are all records, in any type which incorporates written, electronic, magnetic, optical records, scans, x-rays and electrocardiograms that describe or record the strategy, conduct and results of an effort, the factors poignant an effort and the actions taken. Such a record is thought as document and method is documentation. The documents collected before, throughout and once clinical trials give proof that the study was conducted, the information collected is correct and valid which the investigator and sponsor conducted the trial in line with ICH GCP tips is thought as Trial master file. because of exaggerated quality of studies, particularly medical specialty studies, and therefore the issue managing paper TMF’s for various departments, most organizations have moved to eTMF. Archiving may be a key demand to guage post trial observance and analysis and to facilitate any analysis before initiation of an effort and deposit strategy should be developed. It includes the subsequent parts documents to be archived, amount of archiving, location, retrieval or access of archived documents, disaster recovery, procedure of clinical knowledge archiving, archiving by an ethics committee, archiving by the investigator. Archiving of trial documents helps to store knowledge safely and firmly for future use with facilities like secure systems and e-back up.</p>
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Onyancha, Omwoyo Bosire. "Which way records management research?" ESARBICA Journal: Journal of the Eastern and Southern Africa Regional Branch of the International Council on Archives 39, no. 1 (December 24, 2020): 29–45. http://dx.doi.org/10.4314/esarjo.v39i1.3.
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This paper evaluates the keywords and subject areas in records management (RM) publications, as indexed in the Scopus database, with a view to mapping RM research from 1971 to 2018 so as to determine the direction of research in the field. A total of 4 762 documents were obtained from the Scopus database using the term records management and searching within the title, abstract and keywords fields. The data was analysed using VOSviewer software. The findings reveal that interest in RM research has grown as the volume of publications has continued to increase. Whereas there was no dominant area of research in the 1980s, as far as RM research is concerned, the main focus in the 2010s was the management of electronic health records, thereby signalling a shift in RM research from being just an information management exercise to being used for the management of records in the medical and health sector. Other popular research areas in the 2010s were health care, electronic medical record/s, information management, medical computing, information systems, and electronic document exchange. A classification of the RM publications according to Scopus’s broad subject fields revealed that RM research is mainly conducted in computer science, engineering, medicine, and the social sciences. The study predicts a slow growth in the number of RM publications in the next ten years (2019-2028), greater focus on RM in the health sector, and continued dominance of computer-based systems and electronic records as topics of RM research.
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Yu, Bo, Duminda Wijesekera, and Paulo Costa. "Informed Consent in Electronic Medical Record Systems." International Journal of Reliable and Quality E-Healthcare 4, no. 1 (January 2015): 25–44. http://dx.doi.org/10.4018/ijrqeh.2015010103.
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Informed consents, either for treatment or use/disclosure, that protect the privacy of patient information subject to law that in certain circumstances may override patient wishes, are mandatory practice in healthcare. Although the healthcare industry has widely adopted Electronic Medical Record (EMR) systems, consents are still obtained and stored primarily on paper or scanned electronic documents. Integrating a consent management system into an EMR system involves various implementation challenges. The authors show how consents can be electronically obtained and enforced using a system that combines medical workflows and ontologically motivated rule enforcement. Finally, the authors describe an implementation that uses open-source software based addition of these components to an open-source EMR system, so that existing systems needn't be scrapped or otherwise rendered obsolete.
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Holzer, K., and W. Gall. "Utilizing IHE-based Electronic Health Record Systems for Secondary Use." Methods of Information in Medicine 50, no. 04 (2011): 319–25. http://dx.doi.org/10.3414/me10-01-0060.
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SummaryObjectives: Due to the increasing adoption of Electronic Health Records (EHRs) for primary use, the number of electronic documents stored in such systems will soar in the near future. In order to benefit from this development in secondary fields such as medical research, it is important to define requirements for the secondary use of EHR data. Furthermore, analyses of the extent to which an IHE (Integrating the Healthcare Enterprise)-based architecture would fulfill these requirements could provide further information on upcoming obstacles for the secondary use of EHRs.Methods: A catalog of eight core requirements for secondary use of EHR data was deduced from the published literature, the risk analysis of the IHE profile MPQ (Multi-Patient Queries) and the analysis of relevant questions. The IHE-based architecture for cross-domain, patient-centered document sharing was extended to a cross-patient architecture.Results: We propose an IHE-based architecture for cross-patient and cross-domain secondary use of EHR data. Evaluation of this architecture concerning the eight core requirements revealed positive fulfillment of six and the partial fulfillment of two requirements.Conclusions: Although not regarded as a primary goal in modern electronic healthcare, the re-use of existing electronic medical documents in EHRs for research and other fields of secondary application holds enormous potential for the future. Further research in this respect is necessary.
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Rogers, Corinne. "Diplomatics of born digital documents – considering documentary form in a digital environment." Records Management Journal 25, no. 1 (March 16, 2015): 6–20. http://dx.doi.org/10.1108/rmj-03-2014-0021.
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Purpose – This paper aims to explore a new model of “record” that maps traditional attributes of a record onto a technical decomposition of digital records. It compares the core characteristics necessary to call a digital object a “record” in terms of diplomatics or “evidence” in terms of digital forensics. It then isolates three layers of abstraction: the conceptual, the logical and the physical. By identifying the essential elements of a record at each layer of abstraction, a diplomatics of digital records can be proposed. Design/methodology/approach – Digital diplomatics, a research outcome of the International Research on Permanent Authentic Records in Electronic Systems (InterPARES) project, gives archivists a methodology for analyzing the identity and integrity of digital records in electronic systems and thereby assessing their authenticity (Duranti and Preston, 2008; Duranti, 2005) and tracing their provenance. Findings – Digital records consist of user-generated data (content), system-generated metadata identifying source and location, application-generated metadata managing the look and performance of the record (e.g., native file format), application-generated metadata describing the data (e.g., file system metadata OS), and user-generated metadata describing the data. Digital diplomatics, based on a foundation of traditional diplomatic principles, can help identify digital records through their metadata and determine what metadata needs to be captured, managed and preserved. Originality/value – The value and originality of this paper is in the application of diplomatic principles to a deconstructed, technical view of digital records through functional metadata for assessing the identity and authenticity of digital records.
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Kaupa, Stewart, and Ken Chisa. "Adoption of the Electronic Document Records Management System within the Public Sector in Namibia: Exploring the Challenges and Opportunities." International Journal of Operations Management 1, no. 1 (2020): 7–18. http://dx.doi.org/10.18775/ijom.2757-0509.2020.11.4001.
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The concept of records management aided by information and communication technologies (ICTs) has recently been embraced by many institutions across the globe. For example, organisations that have implemented the Electronic Document and Records Management System (EDRMS are deemed to be better equipped to handle both internally and externally generated records. These organisations are said to operate at higher level in terms of efficiency and effectiveness than those that still rely on manual filing. However, despite the well documented benefits that come With the adoption of ICTs for records management, some departments within the public sector in Namibia, such as the Ministry of Home Affairs, Homeland and Security as well as the Office of the Prime Minister are still heavily reliant on manual filing of documents. It is against this background that this study explored factors hindering the adoption of EDRMS in the Office of the Prime Minister (OPM). The study adopted a qualitative research approach to collect, analyse, and interpret data. The data collecting instruments included open-ended questionnaires, face-to-face interviews and observation of the study respondents. Data was analysed using the Atlas.ti tool. The study found that insufficient training of staff on electronic records management, lack of user needs analysis and lack of user involvement before the introduction of the system all contributed to resistance of the EDRMS adoption in the OPM. The study recommends that the OPM must provide adequate training to its employees on electronic records management and on the EDRMS in particular. The OPM should also make provision for the adoption of a change management strategy plan in order to get user buy-in for the new electronic system to be embraced.
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Ozeran, L., C. Hamann, W. Bria, and J. Shoolin. "Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation." Applied Clinical Informatics 04, no. 02 (2013): 293–303. http://dx.doi.org/10.4338/aci-2013-02-r-0012.
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SummaryIn 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of ‘note bloat’. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display. Citation: Shoolin J, Ozeran L, Hamann C, Bria W. II. Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation. Appl Clin Inf 2013; 4: 293–303http://dx.doi.org/10.4338/ACI-2013-02-R-0012
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Ismaili, Ismail, and Refike Sülçevsi. "The Era of Electronic Documents and the Challenges Facing Their Management." Atlanti 25, no. 1 (October 19, 2015): 175–81. http://dx.doi.org/10.33700/2670-451x.25.1.175-181(2015).
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The rapid evolution of computer science and information technology during the past 30 years has led to a revolution in the way of creating electronic documents and information exchanges. Once monolithic, now document is made dynamic in terms of diversification opportunities of commercial exchanges. The central role played by the documents, for the implementation of business processes across different organizations, already enjoys a growing awareness and recognition larger. Standard ISO 15489, Records Management, puts documents at the heart of business processes and promotes their pursuit of an electronic management system that develops them on these premises. The digitization of documents and their creation since inception in electronic form, facilitates the work of the public regarding research in various fields. Therefore, electronic tools of research are not a goal in itself: they are here to allow and assist the researcher and the applicant to identify more quickly the original documents, which are useful for research or his research.
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Jones, Philip. "The role of virtual folders in developing an electronic document and records management system." Records Management Journal 18, no. 1 (February 22, 2008): 53–60. http://dx.doi.org/10.1108/09565690810858514.
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Hardiker, N., J. Kirby, R. Tallis, M. Gonsalkarale, and H. A. Heathfield. "The PEN & PAD Medical Record Model: Development of a Nursing Record for Hospital-based Care of the Elderly." Methods of Information in Medicine 33, no. 05 (1994): 464–72. http://dx.doi.org/10.1055/s-0038-1635061.
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Abstract:The PEN & PAD Medical Record model describes a framework for an information model, designed to meet the requirements of an electronic medical record. This model has been successfully tested in a computer-based record system for General Practitioners as part of the PEN & PAD (GP) Project.Experiences of using the model for developing computer-based nursing records are reported. Results show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient’s care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work has highlighted the need for nurses to clarify and make explicit their uses of information, and also provided them with some tools to assist in this task.
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Manion, F., K. Hsieh, M. Harris, and S. H. Fenton. "Informed Consent." Applied Clinical Informatics 06, no. 03 (2015): 466–77. http://dx.doi.org/10.4338/aci-2014-09-soa-0081.
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Summary Background: Despite efforts to provide standard definitions of terms such as “medical record”, “computer-based patient record”, “electronic medical record” and “electronic health record”, the terms are still used interchangeably. Initiatives like data and information governance, research biorepositories, and learning health systems require availability and reuse of data, as well as common understandings of the scope for specific purposes. Lacking widely shared definitions, utilization of the afore-mentioned terms in research informed consent documents calls to question whether all participants in the research process — patients, information technology and regulatory staff, and the investigative team — fully understand what data and information they are asking to obtain and agreeing to share. Objectives: This descriptive study explored the terminology used in research informed consent documents when describing patient data and information, asking the question “Does the use of the term “medical record” in the context of a research informed consent document accurately represent the scope of the data involved?” Methods: Informed consent document templates found on 17 Institutional Review Board (IRB) websites with Clinical and Translational Science Awards (CTSA) were searched for terms that appeared to be describing the data resources to be accessed. The National Library of Medicine’s (NLM) Terminology Services was searched for definitions provided by key standards groups that deposit terminologies with the NLM. Discussion: The results suggest research consent documents are using outdated terms to describe patient information, health care terminology systems need to consider the context of research for use cases, and that there is significant work to be done to assure the HIPAA Omnibus Rule is applied to contemporary activities such as biorepositories and learning health systems. Conclusions: “Medical record”, a term used extensively in research informed consent documents, is ambiguous and does not serve us well in the context of contemporary information management and governance. Citation: Fenton SH, Manion F, Hsieh K, Harris M. Informed Consent: Does Anyone Really Understand What Is Contained In The Medical Record? Appl Clin Inform 2015; 6: 466–477http://dx.doi.org/10.4338/ACI-2014-09-SOA-0081
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Dujat, C., R. Haux, P. Schmücker, and A. Winter. "Digital Optical Archiving of Medical Records in Hospital Information Systems – A Practical Approach Towards the Computer-based Patient Record?" Methods of Information in Medicine 34, no. 05 (September 1995): 489–97. http://dx.doi.org/10.1055/s-0038-1634622.
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Abstract:The large number of inpatients and outpatients in university hospitals leads to high costs of medical documentation and to an increasing number of medical documents. Due to legal regulations, these medical records have to be stored for 30 years. This implies spatial, organizational, and economical problems. At present, conventional archiving in hospitals often does not satisfy the need to make medical records available for healthcare professionals in a systematic and timely manner. From 1989 to 1993 a pilot study on “digital optical archiving of medical records” was carried out at Heidelberg University Hospital. The study has shown the feasibility of digital optical archiving in hospitals if done under certain conditions. In 1995, Heidelberg University Hospital adopted a procedure for“ digital optical archiving of medical records”. The digital optical archive will first be filled with the medical records of the department of neurosurgery and the endoscopic and echographic images and reports of the department of internal medicine. It is to be expected that this procedure will gradually lead to an integrated functionality on health-care professional workstations, to a hospital-wide use of an electronic patient record, and to media-independent document management systems. The paper focusses on the potentials of digital optical archiving as an integral part of hospital information systems, and on the requirements for the systematic managements of hospital information systems with respect to digital optical archives.
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McMorris, B. J., L. A. Raynor, K. A. Monsen, and K. E. Johnson. "What big size you have! Using effect sizes to determine the impact of public health nursing interventions." Applied Clinical Informatics 04, no. 03 (2013): 434–44. http://dx.doi.org/10.4338/aci-2013-07-ra-0044.
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Summary Background: The Omaha System is a standardized interface terminology that is used extensively by public health nurses in community settings to document interventions and client outcomes. Researchers using Omaha System data to analyze the effectiveness of interventions have typically calculated p-values to determine whether significant client changes occurred between admission and discharge. However, p-values are highly dependent on sample size, making it difficult to distinguish statistically significant changes from clinically meaningful changes. Effect sizes can help identify practical differences but have not yet been applied to Omaha System data. Methods: We compared p-values and effect sizes (Cohen’s d) for mean differences between admission and discharge for 13 client problems documented in the electronic health records of 1,016 young low-income parents. Client problems were documented anywhere from 6 (Health Care Supervision) to 906 (Caretaking/parenting) times. Results: On a scale from 1 to 5, the mean change needed to yield a large effect size (Cohen’s d 0.80) was approximately 0.60 (range = 0.50 – 1.03) regardless of p-value or sample size (i.e., the number of times a client problem was documented in the electronic health record). Conclusions: Researchers using the Omaha System should report effect sizes to help readers determine which differences are practical and meaningful. Such disclosures will allow for increased recognition of effective interventions.
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Levitsky, S. "Electronic document as an element of digital transformation of economic entities." Galic'kij ekonomičnij visnik 68, no. 1 (2021): 44–51. http://dx.doi.org/10.33108/galicianvisnyk_tntu2021.01.044.
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The essence of electronic document management of the enterprise is investigated and the main components of this process organization are revealed in this paper. The place of the electronic document in the enterprise management system is investigated. The peculiarities of transition to the application of electronic documentation are revealed and this process is defined as the main direction of development and improvement of the accounting and financial service of the enterprise. It is proved that digital documents are becoming indispensable for everyone who appreciates comfort, efficiency and high level of security. From practice, it is evident that those companies where digital transformation is started, have gained competitive advantages and are able to process large amount of information. Therefore, working with documents in digital form can, among the other things, save time and space. It is defined that the information support of the management system depends on the quality of documentation, storage and use of previously created information, creates the foundation of the process. All types of documents can be converted to digital form: from simple accounting records, to personal files of various types and formats or multi-page commercial contracts. The most common of these are invoices and bank statements. Specialized equipment, which is available today in this process, makes it possible to scan 250 documents simultaneously in less than 5 minutes. The main barriers for remote operation under pandemic conditions, with the need of continuous computer use, are identified. This process is complicated by paperwork, which requires transportation to employees' homes and the introduction of additional procedures related to information security. This problem provokes a significant increase in interest in digitization among businesses, particularly regarding payroll documentation, due to the large share of paper documents in this process and restrictive measures related to the protection of personal data.
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A. Aziz, Azlina, Zawiyah M. Yusof, Umi Asma' Mokhtar, and Dian Indrayani Jambari. "A Conceptual Model for Electronic Document and Records Management System Adoption in Malaysian Public Sector." International Journal on Advanced Science, Engineering and Information Technology 8, no. 4 (August 18, 2018): 1191. http://dx.doi.org/10.18517/ijaseit.8.4.6376.
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Atiqaf Mahathir, Nur, Irwan Kamaruddin Kadir, Masitah Ahmad, Noorzeelawati Norolazmi, Zakira Imana Harun, Noorsyahirah Mohammad Mobin, and Mohd Ridwan Seman @ Kamarulzaman. "Motivational Factors and Challenges in Managing Record for Mobile Work." International Journal of Engineering & Technology 7, no. 3.7 (July 4, 2018): 253. http://dx.doi.org/10.14419/ijet.v7i3.7.16385.
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Mobile work is not a new phenomenon, but it is a result of better record-keeping records management. Apart from the development of electronic records and record-keeping systems, the practice of these functions continues to be office and paper-based and has supposedly been digitized. Mobile devices and online connections have enabled record creation beyond the office context, on other premises. The several of format in information management created challenges for preservation, until the point when a few researchers called it 'digital archaeology'. Mobile workers did their task in changing and unpredictable areas. Handling of records and document management was either straightforwardly in work situation or as soon as possible after the working hours. It may have implied working while at the same time going, at home or in different places, for example, while going to meeting or courses and customers' premises. Record management was important because it is often necessary to measures the importance areas in the organization. It is also to guarantee their continuity even if individual or that individual might leave the organization. In this issues, when we work as a team example for same related project and all of our colleagues will need the up to date documentation and also records related to their task. They also will share all the information regularly.
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Fontelo, P., E. Rossi, MJ Ackerman, and S. Marceglia. "A Standards-Based Architecture Proposal for Integrating Patient mHealth Apps to Electronic Health Record Systems." Applied Clinical Informatics 06, no. 03 (2015): 488–505. http://dx.doi.org/10.4338/aci-2014-12-ra-0115.
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SummarySummary Background: Mobile health Applications (mHealth Apps) are opening the way to patients’ responsible and active involvement with their own healthcare management. However, apart from Apps allowing patient’s access to their electronic health records (EHRs), mHealth Apps are currently developed as dedicated “island systems”.Objective: Although much work has been done on patient’s access to EHRs, transfer of information from mHealth Apps to EHR systems is still low. This study proposes a standards-based architecture that can be adopted by mHealth Apps to exchange information with EHRs to support better quality of care.Methods: Following the definition of requirements for the EHR/mHealth App information exchange recently proposed, and after reviewing current standards, we designed the architecture for EHR/mHealth App integration. Then, as a case study, we modeled a system based on the proposed architecture aimed to support home monitoring for congestive heart failure patients. We simulated such process using, on the EHR side, OpenMRS, an open source longitudinal EHR and, on the mHealth App side, the iOS platform.Results: The integration architecture was based on the bi-directional exchange of standard documents (clinical document architecture rel2 – CDA2). In the process, the clinician “prescribes” the home monitoring procedures by creating a CDA2 prescription in the EHR that is sent, encrypted and de-identified, to the mHealth App to create the monitoring calendar. At the scheduled time, the App alerts the patient to start the monitoring. After the measurements are done, the App generates a structured CDA2-compliant monitoring report and sends it to the EHR, thus avoiding local storage.Conclusions: The proposed architecture, even if validated only in a simulation environment, represents a step forward in the integration of personal mHealth Apps into the larger health-IT ecosystem, allowing the bi-directional data exchange between patients and healthcare professionals, supporting the patient’s engagement in self-management and self-care.Citation: Marceglia S, Fontelo P, Rossi E, Ackerman MJ. A Standards-Based Architecture Proposal for Integrating Patient mHealth Apps to Electronic Health Record Systems. Appl Clin Inform 2015;6: 488–505http://dx.doi.org/10.4338/ACI-2014-12-RA-0115
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Mosweu, Olefhile, Kelvin Joseph Bwalya, and Athulang Mutshewa. "A probe into the factors for adoption and usage of electronic document and records management systems in the Botswana context." Information Development 33, no. 1 (July 8, 2016): 97–110. http://dx.doi.org/10.1177/0266666916640593.
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Increasingly, public sector organizations are implementing records management systems with a view of improving service delivery. However, adoption and use of these systems has been found to be wanting. This study investigated the factors that influence the adoption and usage of a Document Workflow Management System at the Ministry of Trade and Industry in Botswana using a modified Unified Theory of Acceptance and Use of Technology (UTAUT) as a theoretical lens. The study adopted a survey research design hinged on a positivist approach. A questionnaire, with both open and closed-ended questions, was administered to all 61 Action Officers (with response rate of 87%) who were the key users of the system. The findings of the study indicate that the four major UTAUT constructs accounted for 55% of the variance in explaining behavioural intention to adopt and use the Document Workflow Management System. The study found technophobia, negative attitudes to system use, perceived system complexity and incompatibility with existing information systems as key factors contributing to low adoption and usage of the system. The study proposes a conceptual adoption framework that may be used to guide research and practice in similar contexts.
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Зленко, Алла, and Андрій Іващенко. "TRAINING OF SPECIALISTS IN THE FIELD OF DOCUMENTATION MANAGEMENT AND INFORMATION ACTIVITY: HISTORICAL PREREQUISITES AND PROSPECTS." Society. Document. Communication 12, no. 12 (September 13, 2021): 145–70. http://dx.doi.org/10.31470/2518-7600-2021-12-145-170.
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The article considers the historical preconditions and prospects of professional training of specialists in the field of documentation management and information activities. The modern system of management documentation was preceded by a long period of development and formation associated with changes in socio-economic and socio-political conditions, the relevant historical forms of organization of management processes and its documentation. In turn, the complexity of record-keeping and document-making processes, the development of the document-information market formed the requirements for a document-specialist who would have a universal modern education: possessed knowledge, skills in document science and information activities, and skillfully operated in practice acquired management competencies . The formation of a modern system of documentation management and training of specialists in the relevant field in Ukraine took place in line with the general historical processes of development of our state.
The peculiarities of educational programs of higher education institutions that train applicants in the specialty 029 «Information, library and archival affairs» are analyzed. It is noted that the analysis of educational programs of higher education institutions in the capital and the region shows that modern freelance students receive quality knowledge through clear new educational programs, innovative technologies, open access to information via the Internet and social institutions - libraries and archives. Future professionals are trained to work with information through new electronic tools, banks and databases. The introduction of electronic document management, the experience of leading countries, new technologies significantly increases professional requirements, encourages constant updating and improving the training of Ukrainian document specialists.
In the conclusions it is generalized that document science as a science and as an academic discipline was initiated in the process of development of two branches of practical activity - office work and archival business, within which the logical development of the theory directly depended on practice; at all stages of the transformation of their historical path was directly dependent on the socio-economic demands of society and the improvement of the management segment of document science; The need for highly qualified specialists in the field of document science in the modern labor market is constantly growing, which explains the large number of free economic zones in which high-quality training of document specialists in unique educational programs.
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Essin, D. J. "Intelligent Processing of Loosely Structured Documents as a Strategy for Organizing Electronic Health Care Records." Methods of Information in Medicine 32, no. 04 (1993): 265–68. http://dx.doi.org/10.1055/s-0038-1634938.
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AbstractLoosely structured documents can capture more relevant information about medical events than is possible using today’s popular databases. In order to realize the full potential of this increased information content, techniques will be required that go beyond the static mapping of stored data into a single, rigid data model. Through intelligent processing, loosely structured documents can become a rich source of detailed data about actual events that can support the wide variety of applications needed to run a health-care organization, document medical care or conduct research. Abstraction and indirection are the means by which dynamic data models and intelligent processing are introduced into database systems. A system designed around loosely structured documents can evolve gracefully while preserving the integrity of the stored data. The ability to identify and locate the information contained within documents offers new opportunities to exchange data that can replace more rigid standards of data interchange.
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Matsuo, Toshihiko, Akira Gochi, Tsuyoshi Hirakawa, Tadashi Ito, and Yoshihisa Kohno. "Outpatients Flow Management and Ophthalmic Electronic Medical Records System in University Hospital Using Yahgee Document View." Journal of Medical Systems 34, no. 5 (May 15, 2009): 883–89. http://dx.doi.org/10.1007/s10916-009-9303-8.
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Kovlekov, Ivan, and M. Nesterovich. "ANALYSIS OF ELECTRONIC HR RECORDS MANAGEMENT IN STATE INSTITUTIONS (ON THE EXAMPLE OF THE STATE COMMITTEE ON PRICE POLICY OF THE REPUBLIC OF SAKHA (YAKUTIA))." Management of the Personnel and Intellectual Resources in Russia 9, no. 3 (July 23, 2020): 70–75. http://dx.doi.org/10.12737/2305-7807-2020-70-75.
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In modern conditions, the traditional manual manner of working with documents in business is replaced gradually by the most rational methods of conducting digital office using a personal computer. Nowadays in the software market there is a wide enough choice of various programs for personnel records management at the company. However, the best properly choice often has difficulties connected with the juridical status of the real consumer of the software, the purpose of its activities, computer literacy of workers and the current experience of using a particular software package. The relevance of the problem is due to the fact that the state character of the work and the specific legal framework of the state institution differ significantly from the one of doing business by commercial (private) enterprises, on which are mainly focused the majority of the human resources software applications. The situation of the issue of electronic personnel records management in state institutions was analyzed on the pat-tern of experience with personnel documentation established in the State Committee on Price Policy of the Republic of Sakha (Yakutia). The main aspects of the paperless office work was studied, covering a variety of procedures and routine works with documents, as well as the software itself for dealing with documents of the personnel database of the institution. The article presents the results of studying indicators of electronic document administration and comparative analysis of options for professional personnel management programs. It was noted that at the moment the level of electronic personnel records management in the state institution does not yet fully meet the requirements of modern digital personnel documents management. It was concluded that the destination of further improving the activity of the state institution and raising work on personnel records administration and HR management to a higher level could be solved only if the digital document system for personnel records and accounting will be applied with an operatively updated package of legislative and regulatory framework.
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Lugo, Heinz, Diana Segura, Vasilis Michopoulos, Paul Conway, and Andy West. "Secure Document and Asset Tracking." Journal of Communications Software and Systems 9, no. 1 (March 23, 2013): 24. http://dx.doi.org/10.24138/jcomss.v9i1.155.
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In contract electronics manufacturing, assets and their supporting documents are considered not only valuable intellectual property but also confidential, e.g. due to the military or high value aerospace products they support. Managing transaction records, controlled access and location at all times is of great importance, not only to limit risk but to follow mandatory protocols. In this study a Radio Frequency Identification (RFID) system capable of addressing the criteria described is presented. Both the hardware architecture used along with its limitations and performance in a harsh environment and the software based on a service oriented approach are discussed. The system is evaluated by means of discrete event simulation for different use-case scenarios. Test results show that although the system is capable of recording transactions, a 100% detection rate cannot be guaranteed if the documents are kept inside a metallic cabinet. This proves to be a consequence not of the number of tagged documents present but ofthe surrounding environment. Despite the system’s limitations, which were taken into account during discrete event simulations, a reduction in cost partly due to a reduction in management time of 59% for the manager and 45% for the staff was observed.
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van der Haak, M., M. Hartmann, R. Haux, P. Schmücker, and R. Brandner. "Electronic Signature for Medical Documents – Integration and Evaluation of a Public Key Infrastructure in Hospitals." Methods of Information in Medicine 41, no. 04 (2002): 321–30. http://dx.doi.org/10.1055/s-0038-1634389.
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Summary Objectives: Our objectives were to determine the user-oriented and legal requirements for a Public Key Infrastructure (PKI) for electronic signatures for medical documents, and to translate these requirements into a general model for a signature system. A prototype of this model was then implemented and evaluated in clinical routine use. Methods: Analyses of documents, processes, interviews, observations, and of the available literature supplied the foundations for the development of the signature system model. Eight participants of the Department of Dermatology of the Heidelberg University Medical Center evaluated the implemented prototype from December 2000 to January 2001, during the course of an intervention study. By means of questionnaires, interviews, observations and database analyses, the usefulness and user acceptance of the electronic signature and its integration into electronic discharge letters were established. Results: Since the major part of medical documents generated in a hospital are signature-relevant, they will require electronic signatures in the future. A PKI must meet the multitude of responsibilities and security needs required in a hospital. Also, the signature functionality must be integrated directly into the workflow surrounding document creation. A developed signature model, fulfilling user-oriented and legal requirements, was implemented using hard and software components that conform to the German Signature Law. It was integrated into the existing hospital information system of the Heidelberg University Medical Center. At the end of the intervention study, the average acceptance scores achieved were x = 3,90; sD = 0,42 on a scale of 1 (very negative attitude) to 5 (very positive attitude) for the electronic signature procedure. Acceptance of the integration into computer-supported discharge letter writing reached x = 3,91; sD = 0,47. On average, the discharge letters were completed 7.18 days earlier. Conclusion: The electronic signature is indispensable for the further development of electronic patient records. Application-independent hard and software components, in accordance with the signature law, must be integrated into electronic patient records, and provided to certification services using standardized interfaces. Signature-oriented workflow and document management components are essential for user acceptance in routine clinical use.
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Rahma, Naila, and Nina Mayesti. "Pengendalian Hak Akses pada Electronic Document and Records Management System di Kementerian Kelautan dan Perikanan Republik Indonesia." Lentera Pustaka: Jurnal Kajian Ilmu Perpustakaan, Informasi dan Kearsipan 5, no. 1 (August 4, 2019): 33. http://dx.doi.org/10.14710/lenpust.v5i1.23578.
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Artikel ini membahas Electronic Document and Records Management System (EDRMS) di Kementerian Kelautan dan Perikanan (KKP) Republik Indonesia. KKP telah mengimplementasikan EDRMS bernama Sistem Kearsipan (SIKap) sejak tahun 2012, untuk menunjang pengelolaan rekod elektronik. Fokus pembahasan artikel ini adalah bagaimana KKP mengendalikan akses terhadap rekod elektronik di SIKap, dalam rangka menjaga keamanan sistem. Tujuan penelitian ini adalah untuk mengidentifikasi persyaratan EDRMS dari International Council of Archives (ICA) yang dipenuhi oleh SIKap terkait keamanan rekod elektronik dalam sistem, serta bagaimana hal tersebut diimplementasikan. Data didapatkan melalui observasi partisipatif yang dilakukan berdasarkan persyaratan fungsional EDRMS yang ditetapkan ICA terkait dengan pengendalian akses dan keamanan dalam sistem, yaitu persyaratan nomor 91 hingga 107. Data pelengkap didapatkan melalui wawancara yang dilakukan dengan arsiparis. Hasil temuan penelitian menunjukkan bahwa SIKap mengaplikasikan kebijakan terkait dengan pengendalian akses dan keamanan pada rekod elektronik dalam sistem, yang dikontrol oleh admin. Dari 17 persyaratan yang ditetapkan, 13 persyaratan dipenuhi oleh SIKap, meskipun perlu dilakukan penyesuaian terlebih dahulu agar dapat memenuhi kebutuhan pengelolaan rekod di KKP. Akses dan keamanan pada rekod elektronik di SIKap dikendalikan oleh admin dengan cara mengaplikasikan lapisan keamanan ke masing-masing rekod elektronik dan pengguna sistem, untuk memastikan pengguna hanya dapat mengakses rekod yang dibuka aksesnya untuk mereka.
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Katuu, Shadrack. "Transforming South Africa’s health sector." Journal of Science and Technology Policy Management 7, no. 3 (October 3, 2016): 330–45. http://dx.doi.org/10.1108/jstpm-02-2016-0001.
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Purpose The purpose of this paper is to explore the challenges of transforming South Africa’s health sector through the country’s eHealth Strategy and particularly one of its key components, the implementation of an integrated Electronic Document and Records Management System (EDRMS). Design/methodology/approach The study conducted an extensive review of literature and used it as a basis to analyse the challenges as well as opportunities in South Africa’s transformation path within its health sector based on the nation’s eHealth Strategy. Findings South Africa’s health sector faces three main transformation challenges: inequity, legacy of fragmentation and a service delivery structure biased towards curative rather than preventive services. Health information systems provide a solid platform for improving efficiency but, within South Africa, these systems have been highly heterogeneous. A recent study showed the country had more than 40 individual health information systems scattered in all provinces, with over 50 per cent not adhering to any national or international standards and more than 25 per cent being stand-alone applications that shared information neither locally nor externally. The eHealth Strategy offers a robust platform to start addressing the legacy of fragmentation and lack of interoperability. However, it also raises a few other concerns, including the use of different terminology such as Electronic Medical Record (EMR) interchangeable with Electronic Health Record (EHR), or EDRMS parallel with Electronic Content Management (ECM). In addition, there is the opportunity to explore the use of the maturity model concept in the EDRMS implementation experiences within South Africa. Originality/value This paper demonstrated the complex nature of the legacy of fragmentation in South Africa’s health information systems and explored three aspects relating to terminology as well as maturity models that should be considered in the country’s future eHealth Strategy.
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Abdullah, Azlan Long, Zawiyah Mohammad Yusof, and Umi Asma Mokhtar. "Factors influencing the implementation of electronic records and information management." Records Management Journal 30, no. 1 (August 31, 2019): 81–99. http://dx.doi.org/10.1108/rmj-10-2018-0043.
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Purpose The purpose of this paper is to explore, identify and gain insight into factors related to electronic records and information management (e-RIM) issues and their influence on the implementation of e-RIM initiative in military service in Malaysia. This exploration was conducted via a literature review and case study. Design/methodology/approach This study adopted a qualitative approach and used a case study involving two army departments in Malaysia. Interviews triangulated by document content analysis and observations were used for data collection. The data were analysed using a directional content analysis approach. Findings This study reveals that people, organizations, technology and processes are the interrelated contexts underlying e-RIM issues which inevitably influence the implementation of e-RIM initiatives. Competency and leadership, governance structure, culture and strategic planning, technology development and record-keeping process are the main factors impacting such efforts, in turn forming potential obstacles for organizations implementing such initiatives. Research limitations/implications The research approach and design adopted and the sample size were insufficient for generalization of the findings. Practical implications This study shows that e-RIM initiatives pose greater challenges related to various issues that cause difficulties in improving and implementing the initiative. Thus, it is crucial for organizations to ascertain and comprehend the factors that influence e-RIM initiatives prior to formulating strategies and approaches in addressing those factors, which would in turn affect the implementation of e-RIM initiatives. Originality/value This study provides insights into the fundamental factors embracing the e-RIM issues which influence the initiatives, and thereby fosters further discussion and research in the subject matter in Malaysia.
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Sidorova, Victoria, and Evgeny Petrov. "Electronic calendar as an element of digital IT-farm management." BIO Web of Conferences 27 (2020): 00150. http://dx.doi.org/10.1051/bioconf/20202700150.
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Management of on-farm processes in animal husbandry with an analogue primary accounting system (acts, journals, statements, certificates, cards, etc.) was carried out using paper, and later electronic reporting forms. In the paper flow of zootechnical accounting, the document contained 70-250 records, the processing and maintenance of which took a lot of time: when entering 25-30 characters per minute, 1.5-2.5 hours; in electronic forms the number of printed characters has been reduced by 5-10 times, or up to 10-20 entries per document per minute. The transition from paper reporting to electronic reporting stabilized the speed of accounting and the number of personnel: 4 accountants were replaced by 1 computer operator, while expanding the database. The digitalization of the electronic calendar as a control element for a “smart” farm is becoming a new stage in optimizing work with document flow. The electronic calendar monitors economic and economic processes, time intervals, problems, automatically generates databases of production processes depending on the “key feature”, for example, the indicator “live weight”: animals that meet the condition С0>Cc, who have collected the necessary live weight, pass to the next production cycle. Mass “С”. Animals С0 = – Cc, that do not meet the requirement, are transferred to the emergency implementation group as economically ineffective for further fattening. The program of cyclical formation of production groups Cij depending on the weighing results, is described by a simulation model U = f(x, p), where U is the state of the modeled component, f are the main functional dependencies, x are variables, p are parameters.
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Wu, Y., J. C. Denny, S. T. Rosenbloom, R. A. Miller, D. A. Giuse, M. Song, and H. Xu. "A Preliminary Study of Clinical Abbreviation Disambiguation in Real Time." Applied Clinical Informatics 06, no. 02 (2015): 364–74. http://dx.doi.org/10.4338/aci-2014-10-ra-0088.
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SummaryObjective: To save time, healthcare providers frequently use abbreviations while authoring clinical documents. Nevertheless, abbreviations that authors deem unambiguous often confuse other readers, including clinicians, patients, and natural language processing (NLP) systems. Most current clinical NLP systems “post-process” notes long after clinicians enter them into electronic health record systems (EHRs). Such post-processing cannot guarantee 100% accuracy in abbreviation identification and disambiguation, since multiple alternative interpretations exist.Methods: Authors describe a prototype system for real-time Clinical Abbreviation Recognition and Disambiguation (rCARD) – i.e., a system that interacts with authors during note generation to verify correct abbreviation senses. The rCARD system design anticipates future integration with web-based clinical documentation systems to improve quality of healthcare records. When clinicians enter documents, rCARD will automatically recognize each abbreviation. For abbreviations with multiple possible senses, rCARD will show a ranked list of possible meanings with the best predicted sense at the top. The prototype application embodies three word sense disambiguation (WSD) methods to predict the correct senses of abbreviations. We then conducted three experments to evaluate rCARD, including 1) a performance evaluation of different WSD methods; 2) a time evaluation of real-time WSD methods; and 3) a user study of typing clinical sentences with abbreviations using rCARD.Results: Using 4,721 sentences containing 25 commonly observed, highly ambiguous clinical abbreviations, our evaluation showed that the best profile-based method implemented in rCARD achieved a reasonable WSD accuracy of 88.8% (comparable to SVM – 89.5%) and the cost of time for the different WSD methods are also acceptable (ranging from 0.630 to 1.649 milliseconds within the same network). The preliminary user study also showed that the extra time costs by rCARD were about 5% of total document entry time and users did not feel a significant delay when using rCARD for clinical document entry.Conclusion: The study indicates that it is feasible to integrate a real-time, NLP-enabled abbreviation recognition and disambiguation module with clinical documentation systems.Citation: Wu Y, Denny JC, Rosenbloom ST, Miller RA, Giuse DA, Song M, Xu H. A preliminary study of clinical abbreviation disambiguation in real time. Appl Clin Inf 2015; 6: 364–374http://dx.doi.org/10.4338/ACI-2014-10-RA-0088
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Lu, Y., C. J. Vitale, P. L. Mar, F. Chang, N. Dhopeshwarkar, R. A. Rocha, and L. Zhou. "Representation of Information about Family Relatives as Structured Data in Electronic Health Records." Applied Clinical Informatics 05, no. 02 (2014): 349–67. http://dx.doi.org/10.4338/aci-2013-10-ra-0080.
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SummaryBackground: The ability to manage and leverage family history information in the electronic health record (EHR) is crucial to delivering high-quality clinical care.Objectives: We aimed to evaluate existing standards in representing relative information, examine this information documented in EHRs, and develop a natural language processing (NLP) application to extract relative information from free-text clinical documents.Methods: We reviewed a random sample of 100 admission notes and 100 discharge summaries of 198 patients, and also reviewed the structured entries for these patients in an EHR system’s family history module. We investigated the two standards used by Stage 2 of Meaningful Use (SNOMED CT and HL7 Family History Standard) and identified coverage gaps of each standard in coding relative information. Finally, we evaluated the performance of the MTERMS NLP system in identifying relative information from free-text documents.Results: The structure and content of SNOMED CT and HL7 for representing relative information are different in several ways. Both terminologies have high coverage to represent local relative concepts built in an ambulatory EHR system, but gaps in key concept coverage were detected; coverage rates for relative information in free-text clinical documents were 95.2% and 98.6%, respectively. Compared to structured entries, richer family history information was only available in free-text documents. Using a comprehensive lexicon that included concepts and terms of relative information from different sources, we expanded the MTERMS NLP system to extract and encode relative information in clinical documents and achieved a corresponding precision of 100% and recall of 97.4%.Conclusions: Comprehensive assessment and user guidance are critical to adopting standards into EHR systems in a meaningful way. A significant portion of patients’ family history information is only documented in free-text clinical documents and NLP can be used to extract this information.Citation: Zhou L, Lu Y, Vitale CJ, Mar PL, Chang F, Dhopeshwarkar N, Rocha RA. Representation of information about family relatives as structured data in electronic health records. Appl Clin Inf 2014; 5: 349–367 http://dx.doi.org/10.4338/ACI-2013-10-RA-0080
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Marchenko, Olga V. "Legal regime of records management in Russian executive authorities." Law Enforcement Review 4, no. 3 (October 5, 2020): 76–85. http://dx.doi.org/10.24147/2542-1514.2020.4(3).76-85.
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The subject. Problems of legislative regulation of information and records management in executive authorities activity are raised. The purpose of the article is confirmation or confutation of the hypothesis that the lack of centralization of legal regulation of records management in Russian executive authorities causes problems in public governance. The methodology includes formal-legal method, systematic approach, formal-logical method, analysis, synthesis. The main results of research. The "legal regime of records management" is the established legal procedure for documenting information and organizing work with documents. The activity of executive authorities for the production of documented information has its own specifics. If analyze the normative legal acts, it can be stated that the system of legislation that regulates the implementation of documentation operations in the structure of executive authorities of the Russian Federation needs to be modified by specifying a number of existing provisions and including new ones. Conclusions. Despite the fact that currently there is a fairly developed regulatory framework for documentation management, a significant part of the issues related to the organization and technology of working with documents is not sufficiently regulated. In particular, this applies to the organization of electronic document management in the activities of executive authorities. The following measures could help to solve this and many other problems, and improve the state of documentation support for governance in the country: adaptation of international standards in the field of documentation maintenance of management to Russian conditions; restoration of state regulation of records management in executive authorities at all levels; creation of a federal executive authority responsible for improving, controlling, and regulating the documentation maintenance of governance; adoption of the federal law, which would fix the general principles and the most significant provisions of records management.
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Baynham, Anthony. "Audit of the use of the physical health improvement (PHIT) to document physical health examination on an electronic health record at a mental health trust in Manchester." BJPsych Open 7, S1 (June 2021): S6—S7. http://dx.doi.org/10.1192/bjo.2021.77.
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AimsThe audit aimed to identify: The percentage of patients with Initial Physical Examination (IPE), ECG and bloods on admission being completed; If IPE, bloods and ECG result are documented on PHIT; To identify reasons for these interventions not being completed and review if refusal is being appropriately documented.Background“The Five Year Forward View for Mental Health NHS” report highlighted the poor physical health of those with mental health problems when compared to those without. In order to improve the identification and treatment of physical health problems within mental health inpatients, blood test results, physical examination and ECG results should be recorded and reviewed regularly. Within Greater Manchester Mental Health trust, the electronic records system PARIS contains a specific care document to record physical health interventions, known as the PHIT tool. The inpatient unit Park House, had recently changed to the PARIS system prior to this audit and the use of PHIT tool to monitor physical health parameters was considered a priority by the management team.MethodAll admissions to Park House inpatient unit, Manchester in April 2019 were audited. Patients were identified using a report prepared by Business Intelligence. Electronic notes were reviewed for evidence of physical interventions on admission and input of these data to the PHIT tool. Using a retrospective review of electronic notes, relevant information was anonymised and collected to a spreadsheet for further analysis. Inclusion/exclusion criteria was based on local conditions and practical consideration.ResultAn initial sample of 140 was reduced to 89 patients following application of inclusion/exclusion criteria. Of the 89 patients included, 73% had an IPE, 84% of patients had admission blood tests and 74% had an admission ECG. Recording of parameters on the PHIT tool was lower than expected with information recorded in 33–42% of patients. Where patients had refused IPE, ECG or bloods, a valid reason for refusal was documented between 63–91% of patients.ConclusionThe initial audit identified that most patients had IPE, ECG and bloods but this was documented appropriately in less than 42% had this appropriately documented.Interventions to improve this rate were developed, focussing on increasing completion of IPE, ECG and bloods as well as improving documentation. The completion of PHIT document is now monitored regularly. The re-audit to identify the magnitude of improvements from these interventions is currently underway.
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Larsen, Ethan, Daniel Hoffman, Carlos Rivera, Brian M. Kleiner, Christian Wernz, and Raj M. Ratwani. "Continuing Patient Care during Electronic Health Record Downtime." Applied Clinical Informatics 10, no. 03 (May 2019): 495–504. http://dx.doi.org/10.1055/s-0039-1692678.
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Introduction Electronic health record (EHR) downtime is any period during which the EHR system is fully or partially unavailable. These periods are operationally disruptive and pose risks to patients. EHR downtime has not sufficiently been studied in the literature, and most hospitals are not adequately prepared. Objective The objective of this study was to assess the operational implications of downtime with a focus on the clinical laboratory, and to derive recommendations for improved downtime contingency planning. Methods A hybrid qualitative–quantitative study based on historic performance data and semistructured interviews was performed at two mid-Atlantic hospitals. In the quantitative analysis, paper records from downtime events were analyzed and compared with normal operations. To enrich this quantitative analysis, interviews were conducted with 17 hospital employees, who had experienced several downtime events, including a hospital-wide EHR shutdown. Results During downtime, laboratory testing results were delayed by an average of 62% compared with normal operation. However, the archival data were incomplete due to inconsistencies in the downtime paper records. The qualitative interview data confirmed that delays in laboratory result reporting are significant, and further uncovered that the delays are often due to improper procedural execution, and incomplete or incorrect documentation. Interviewees provided a variety of perspectives on the operational implications of downtime, and how to best address them. Based on these insights, recommendations for improved downtime contingency planning were derived, which provide a foundation to enhance Safety Assurance Factors for EHR Resilience guides. Conclusion This study documents the extent to which downtime events are disruptive to hospital operations. It further highlights the challenge of quantitatively assessing the implication of downtimes events, due to a lack of otherwise EHR-recorded data. Organizations that seek to improve and evaluate their downtime contingency plans need to find more effective methods to collect data during these times.
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Scott, Ian A., Clair Sullivan, and Andrew Staib. "Going digital: a checklist in preparing for hospital-wide electronic medical record implementation and digital transformation." Australian Health Review 43, no. 3 (2019): 302. http://dx.doi.org/10.1071/ah17153.
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Objective In an era of rapid digitisation of Australian hospitals, practical guidance is needed in how to successfully implement electronic medical records (EMRs) as both a technical innovation and a major transformative change in clinical care. The aim of the present study was to develop a checklist that clearly and comprehensively defines the steps that best prepare hospitals for EMR implementation and digital transformation. Methods The checklist was developed using a formal methodological framework comprised of: literature reviews of relevant issues; an interactive workshop involving a multidisciplinary group of digital leads from Queensland hospitals; a draft document based on literature and workshop proceedings; and a review and feedback from senior clinical leads. Results The final checklist comprised 19 questions, 13 related to EMR implementation and six to digital transformation. Questions related to the former included organisational considerations (leadership, governance, change leaders, implementation plan), technical considerations (vendor choice, information technology and project management teams, system and hardware alignment with clinician workflows, interoperability with legacy systems) and training (user training, post-go-live contingency plans, roll-out sequence, staff support at point of care). Questions related to digital transformation included cultural considerations (clinically focused vision statement and communication strategy, readiness for change surveys), management of digital disruption syndromes and plans for further improvement in patient care (post-go-live optimisation of digital system, quality and benefit evaluation, ongoing digital innovation). Conclusion This evidence-based, field-tested checklist provides guidance to hospitals planning EMR implementation and separates readiness for EMR from readiness for digital transformation. What is known about the topic? Many hospitals throughout Australia have implemented, or are planning to implement, hospital wide electronic medical records (EMRs) with varying degrees of functionality. Few hospitals have implemented a complete end-to-end digital system with the ability to bring about major transformation in clinical care. Although the many challenges in implementing EMRs have been well documented, they have not been incorporated into an evidence-based, field-tested checklist that can practically assist hospitals in preparing for EMR implementation as both a technical innovation and a vehicle for major digital transformation of care. What does this paper add? This paper outlines a 19-question checklist that was developed using a formal methodological framework comprising literature review of relevant issues, proceedings from an interactive workshop involving a multidisciplinary group of digital leads from hospitals throughout Queensland, including three hospitals undertaking EMR implementation and one hospital with complete end-to-end EMR, and review of a draft checklist by senior clinical leads within a statewide digital healthcare improvement network. The checklist distinguishes between issues pertaining to EMR as a technical innovation and EMR as a vehicle for digital transformation of patient care. What are the implications for practitioners? Successful implementation of a hospital-wide EMR requires senior managers, clinical leads, information technology teams and project management teams to fully address key operational and strategic issues. Using an issues checklist may help prevent any one issue being inadvertently overlooked or underemphasised in the planning and implementation stages, and ensure the EMR is fully adopted and optimally used by clinician users in an ongoing digital transformation of care.
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Sulkers, Heather, Tania Tajirian, Jane Paterson, Daniela Mucuceanu, Tracey MacArthur, John Strauss, Kamini Kalia, Gillian Strudwick, and Damian Jankowicz. "Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report." JAMIA Open 2, no. 1 (September 19, 2018): 35–39. http://dx.doi.org/10.1093/jamiaopen/ooy044.
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Abstract Although electronic health record systems have been implemented in many health settings globally, how organizations can best implement these systems to improve medication safety in mental health contexts is not well documented in the literature. The purpose of this case report is to describe how a mental health hospital in Toronto, Canada, leveraged the process of obtaining Healthcare Information Management Systems Society (HIMSS) Stage 7 on the Electronic Medical Record Adoption Model to improve clinical care specific to medication safety in its inpatient settings. Examples of how the organization met several of these HIMSS criteria are described as they relate to utilizing data from the system to support clinician practice and/or decision-making for medication safety.
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Savova, G. K., K. C. Kipper-Schuler, J. F. Hurdle, and S. M. Meystre. "Extracting Information from Textual Documents in the Electronic Health Record: A Review of Recent Research." Yearbook of Medical Informatics 17, no. 01 (August 2008): 128–44. http://dx.doi.org/10.1055/s-0038-1638592.
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Summary Objectives We examine recent published research on the extraction of information from textual documents in the Electronic Health Record (EHR). Methods Literature review of the research published after 1995, based on PubMed, conference proceedings, and the ACM Digital Library, as well as on relevant publications referenced in papers already included. Results 174 publications were selected and are discussed in this review in terms of methods used, pre-processing of textual documents, contextual features detection and analysis, extraction of information in general, extraction of codes and of information for decision-support and enrichment of the EHR, information extraction for surveillance, research, automated terminology management, and data mining, and de-identification of clinical text. Conclusions Performance of information extraction systems with clinical text has improved since the last systematic review in 1995, but they are still rarely applied outside of the laboratory they have been developed in. Competitive challenges for information extraction from clinical text, along with the availability of annotated clinical text corpora, and further improvements in system performance are important factors to stimulate advances in this field and to increase the acceptance and usage of these systems in concrete clinical and biomedical research contexts.
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Ab Aziz, Azlina, Zawiyah M. Yusof, and Umi A. Mokhtar. "Electronic Document and Records Management System (EDRMS) Adoption in Public Sector – Instrument’s Content Validation Using Content Validation Ratio (CVR)." Journal of Physics: Conference Series 1196 (March 2019): 012057. http://dx.doi.org/10.1088/1742-6596/1196/1/012057.
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Albuquerque, Kevin, Kellie Rodgers, Ann Spangler, Asal Rahimi, and DuWayne Willett. "Electronic Medical Record–Based Radiation Oncology Toxicity Recording Instrument Aids Benchmarking and Quality Improvement in the Clinic." Journal of Oncology Practice 14, no. 3 (March 2018): e186-e193. http://dx.doi.org/10.1200/jop.2017.025163.
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Purpose: The on-treatment visit (OTV) for radiation oncology is essential for patient management. Radiation toxicities recorded during the OTV may be inconsistent because of the use of free text and the lack of treatment site–specific templates. We developed a radiation oncology toxicity recording instrument (ROTOX) in a health system electronic medical record (EMR). Our aims were to assess improvement in documentation of toxicities and to develop clinic toxicity benchmarks. Methods: A ROTOX that was based on National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.0) with flow-sheet functionality was developed in the EMR. Improvement in documentation was assessed at various time intervals. High-grade toxicities (ie, grade ≥ 3 by CTCAE) by site were audited to develop benchmarks and to track nursing and physician actions taken in response to these. Results: A random sample of OTV notes from each clinic physician before ROTOX implementation was reviewed and assigned a numerical document quality score (DQS) that was based on completeness and comprehensiveness of toxicity grading. The mean DQS improved from an initial level of 41% to 99% (of the maximum possible DQS) when resampled at 6 months post-ROTOX. This high-level DQS was maintained 3 years after ROTOX implementation at 96% of the maximum. For months 7 to 9 after implementation (during a 3-month period), toxicity grading was recorded in 4,443 OTVs for 698 unique patients; 107 episodes of high-grade toxicity were identified during this period, and toxicity-specific intervention was documented in 95%. Conclusion: An EMR-based ROTOX enables consistent recording of treatment toxicity. In a uniform sample of patients, local population toxicity benchmarks can be developed, and clinic response can be tracked.
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Garcia-Webb, M., and ES Chen. "An Analysis of Free-Text Alcohol Use Documentation in the Electronic Health Record." Applied Clinical Informatics 05, no. 02 (2014): 402–15. http://dx.doi.org/10.4338/aci-2013-12-ra-0101.
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SummaryBackground: Alcohol use is a significant part of a patient’s history, but details about consumption are not always documented. Electronic Health Record (EHR) systems have the potential to improve assessment of alcohol use and misuse; however, a challenge is that critical information may be documented primarily in free-text rather than in a structured and standardized format, thereby limiting its use.Objective: To characterize the use and contents of free-text documentation for alcohol use in the social history module of an EHR.Methods: This study involved a retrospective analysis of 500 alcohol use entries that include structured fields as well as a free-text comment field. Two coding schemes were developed and used to analyze these entries for: (1) quantifying the reasons for using free-text comments and (2) categorizing information in the free-text into separate elements. In addition, for entries indicating possible alcohol misuse, a preliminary review of other structured parts of the EHR was conducted to determine if this was also documented elsewhere.Results: The top three reasons for using free-text were limited ability to describe alcohol use frequency (75%), amount (22%), and status (18%) with available structured fields. Within the free-text, descriptions of frequency were most common (79%) using words or phrases conveying occasional (61%), daily (13%), or weekly (12%) use. Of the 36 cases suggesting alcohol misuse, 44% had mention of alcohol problems in the problem list or past medical history.Conclusions: Based on the early findings, implications for improving the structured collection and use of alcohol use information in the EHR are provided in four areas: (1) system enhancements, (2) user training, (3) decision support, and (4) standards. Next steps include examining how alcohol use is documented in other parts of the EHR (e.g., clinical notes) and how documentation practices vary based on patient, provider, and clinic characteristics.Citation: Chen ES, M. Garcia-Webb M. An analysis of free-text alcohol use documentation in the electronic health record: Early findings and implications. Appl Clin Inf 2014; 5: 402–415 http://dx.doi.org/10.4338/ACI-2013-12-RA-0101
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Aziz, Azlina Ab, Zawiyah M. Yusof, Umi Asma’ Mokhtar, and Dian Indrayani Jambari. "Establishing Policy for the Implementation of Electronic Document and Records Management System in Public Sector in Malaysia: The Influencing Factors." Advanced Science Letters 23, no. 11 (November 1, 2017): 10732–36. http://dx.doi.org/10.1166/asl.2017.10141.
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Mosweu, Olefhile, Kelvin Bwalya, and Athulang Mutshewa. "Examining factors affecting the adoption and usage of document workflow management system (DWMS) using the UTAUT model." Records Management Journal 26, no. 1 (March 21, 2016): 38–67. http://dx.doi.org/10.1108/rmj-03-2015-0012.
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Purpose – Public sector organisations in the developing world contexts have hugely invested in procuring information management systems such as the electronic document and records management system (EDRMS). The procurement and implementation of these systems come at a huge cost to taxpayers. Unfortunately, most of these systems remain white elephants due to reluctance by the anticipated users to adopt and use them in their information management endeavours. This study aims to understand Action Officers’ perceptions of, adoption and/or usage of the document workflow management system (DWMS) at the Ministry of Trade and Industry in Botswana. The DWMS is one type of EDRMS. Design/methodology/approach – The survey uses a questionnaire distributed in Gaborone, Botswana to gather data on the perceptions of anticipated users of the DWMS. The study used a modified form of UTAUT as a theoretical lens to explore user’s perception on the adoption and use of DWMS at the Ministry of Trade and Industry, Botswana. The population of the study was 68. A total of 53 (86.89 per cent) out of 61 users of DWMS were purposively sampled and responded to the questionnaire. The rest took part in interviews. Findings – Negative attitudes to computers, computer anxiety, the complexity of DWMS and its incompatibility to current working practices influences Action and Records Officers’ unwillingness to adopt and use the DWMS. Research limitations/implications – This study was limited to the Ministry of Trade and Industry (MTI)’s Department of Corporate Services, so its findings cannot be statistically generalized to the MTI as a whole. Another limitation relates to the secretive nature of staff in some government departments which lead them to provide partial information related to the study. Finally, the additional technology adoption factors discovered from interviews (i.e. computer anxiety, incompatibility of DWMS to current work practices, negative attitudes to system use and complexity of the system) have not been empirically tested to ascertain their validity. This provides an opportunity for a future study to empirically test the said additional factors. Practical implications – To mitigate the lower DWMS adoption and usage, robust change management and communication were identified as some of the critical factors that should be considered. The identified factors may be used in drafting a model to aid the implementation of DWMS in Botswana or in a contextually similar environment in the developing world. Originality/value – This study provides empirical evidence from an original study.