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Quality of the electronic medical record

Stephen Tsaur, Lacey Gleason, Yuli Kim
Quality indicators for adult congenital heart disease (ACHD) were recently published due to a lack of consensus regarding delivery of care to adults with congenital heart disease (CHD). The objective of this study was to examine adherence to quality indicators for the care of patients with tetralogy of Fallot. Adults with tetralogy of Fallot seen in outpatient cardiology clinics at a tertiary care facility between July 2014 and June 2015 were included, and electronic medical records for each visit were reviewed...
August 18, 2018: Pediatric Cardiology
A F Santoro, S M Shear, A Haber
BACKGROUND: Associations between childhood adversity and negative health outcomes are well documented within the general population; however, this relationship has yet to be confirmed in adults with intellectual and developmental disabilities (I/DD). Bridging the gap between public health and I/DD research is critical in order to better understand the ways in which the health of people with I/DD are compromised by adversity and social disadvantage and to develop preventative care frameworks and health-promoting practices specifically for adults with I/DD...
August 17, 2018: Journal of Intellectual Disability Research: JIDR
Ty Kirkpatrick, Bethany Zimmerman, Karl LeBlanc
BACKGROUND: Robotic-assisted surgery has proved to be a valuable modality in specialties such as urology and gynecology and has gained wide acceptance in those fields. Its value in general surgery, however, has had a slower acceptance rate among surgeons. This study reviews my first 150 cases using the robot for one of the most common general surgery operations-the repair of hernias. MATERIALS AND METHODS: All robotic hernia cases performed by a single surgeon were documented in an Excel� (Microsoft Corporation, Redmond, Washington) spreadsheet beginning in April, 2014...
August 14, 2018: Surgical Technology International
Cheryl Battersby, Yevgeniy Statnikov, Shalini Santhakumaran, Daniel Gray, Neena Modi, Kate Costeloe
BACKGROUND: The National Neonatal Research Database (NNRD) is a rich repository of pre-defined clinical data extracted at regular intervals from point-of-care, clinician-entered electronic patient records on all admissions to National Health Service neonatal units in England, Wales, and Scotland. We describe population coverage for England and assess data completeness and accuracy. METHODS: We determined population coverage of the NNRD in 2008-2014 through comparison with data on live births in England from the Office for National Statistics...
2018: PloS One
John C Matulis, Frederick North
INTRODUCTION: Apologizing to patients is an encouraged practice, yet little is known about how and why providers apologize and what insights apologies could provide in improving quality and safety. OBJECTIVE: The aim of the study was to determine whether provider apologies in the electronic health record could identify patient safety concerns and opportunities for improvement. METHODS: After performing a free-text search, we randomly selected 100 clinical notes from 1685 available containing terminology related to apology...
July 17, 2018: Journal of Patient Safety
Sebastian Schneeweiss, Robert J Glynn
Healthcare database analyses (claims, electronic health records) have been identified by various regulatory initiatives, including the 21st Century Cures Act and Prescription Drug User Fee Act ("PDUFA"), as useful supplements to randomized clinical trials to generate evidence on the effectiveness, harm, and value of medical products in routine care. Specific applications include accelerated drug approval pathways and secondary indications for approved medical products. Such real-world data ("RWD") analyses reflect how medical products impact health outside a highly controlled research environment...
May 2018: American Journal of Law & Medicine
Rebecca Brundin-Mather, Andrea Soo, Danny J Zuege, Daniel J Niven, Kirsten Fiest, Christopher J Doig, David Zygun, Jamie M Boyd, Jeanna Parsons Leigh, Sean M Bagshaw, Henry T Stelfox
PURPOSE: This study measured the quality of data extracted from a clinical information system widely used for critical care quality improvement and research. MATERIALS AND METHODS: We abstracted data from 30 fields in a random sample of 207 patients admitted to nine adult, medical-surgical intensive care units. We assessed concordance between data collected: (1) manually from the bedside system (eCritical MetaVision) by trained auditors, and (2) electronically from the system data warehouse (eCritical TRACER)...
July 22, 2018: Journal of Critical Care
Rebecca E Sadun, Melissa A Wells, Stephen J Balevic, Victoria Lackey, Erica J Aldridge, Nicholas Holdgagte, Samya Mohammad, Lisa G Criscione-Schreiber, Megan E B Clowse, Mamata Yanamadala
Teratogenic medications are often prescribed to women of childbearing age with autoimmune diseases. Literature suggests that appropriate use of contraception among these women is low, potentially resulting in high-risk unintended pregnancies. Preliminary review in our clinic showed suboptimal documentation of women's contraceptive use. We therefore designed a quality improvement initiative to target three process measures: documentation of contraception usage and type, contraception counselling and provider action after counselling...
2018: BMJ Open Quality
Catarina Vitor, Afonso Cavaco
Introduction: Low health literacy in Portugal, revealed by limited patients' knowledge of their medication, may be improved by written information that is individually tailored for each patient. Tailored content can be produced through computer software and delivered by community pharmacies to patients. Objective: To assess community pharmacists' real-life management, usage and perceived utility of software developed to produce individually tailored patient leaflets at community pharmacies...
2018: AIMS Public Health
Kärt Allvee, Mati Rahu, Kai Haldre, Helle Karro, Kaja Rahu
BACKGROUND: Information regarding in vitro fertilization (IVF) as a pregnancy risk factor (yes/ no) is stored in each birth record of the Estonian Medical Birth Registry (EMBR). This study aimed to assess the validity of registration of newborns' IVF status in the EMBR. METHODS: To identify the newborns conceived by IVF, the birth records in the EMBR were compared to individual records on the embryo transfer procedures in the Estonian Health Insurance Fund (EHIF) database as a reference...
August 8, 2018: Reproductive Health
Hadi Kharrazi, Claudia P Gonzalez, Kevin B Lowe, Timothy R Huerta, Eric W Ford
BACKGROUND: The Meaningful Use (MU) program has promoted electronic health record adoption among US hospitals. Studies have shown that electronic health record adoption has been slower than desired in certain types of hospitals; but generally, the overall adoption rate has increased among hospitals. However, these studies have neither evaluated the adoption of advanced functionalities of electronic health records (beyond MU) nor forecasted electronic health record maturation over an extended period in a holistic fashion...
August 7, 2018: Journal of Medical Internet Research
Lovya George, Jasminkumar B Patel, Nesha Park, Winston M Manimtim
Hearing loss is the most common congenital birth defect. In 2007, American Academy of Pediatrics updated the hearing screen guidelines to recommend hearing screen by 1 month of age, diagnostic evaluation by 3 months, and early interventions by 6 months. Early interventions have been shown to improve developmental outcome in children with hearing loss. Infants admitted to the neonatal intensive care unit (NICU) are at higher risk for hearing loss. For infants born before 34 weeks' gestation, there are no guidelines for initial hearing screen...
August 6, 2018: American Journal of Perinatology
Jane M Zhu, Viren Patel, Judy A Shea, Mark D Neuman, Rachel M Werner
A goal of Medicare's bundled payment models is to improve quality and control costs after hospital discharge. Little is known about how participating hospitals are focusing their efforts to achieve these objectives, particularly around the use of skilled nursing facilities (SNFs). To understand hospitals' approaches, we conducted semistructured interviews with an executive or administrator in each of twenty-two hospitals and health systems participating in Medicare's Comprehensive Care for Joint Replacement model or its Bundled Payments for Care Improvement initiative for lower extremity joint replacement episodes...
August 2018: Health Affairs
Sean B O'Donnell, Martha K Nicholson, Jason W Boland
Background: Benzodiazepines and Z-drugs are commonly used in patients with cancer for the management of symptoms such as anxiety, agitation and dyspnoea. Clinical staff, patients and relatives have concerns about the impact of these drugs on survival. This potentially decreases prescribing leading to suboptimal symptom control. The aim of this systematic review was to find and assimilate the evidence assessing the association of benzodiazepines and Z-drugs with survival in patients with cancer, to assist in clinical decision-making regarding the use of these drugs in cancer patients...
March 2018: BMJ Supportive & Palliative Care
Lukasz J Nowak, Karolina M Nowak
BACKGROUND: The area of application of electronic stethoscopes in medical diagnostics covers the scope of usability of the acoustic stethoscopes, from which they have evolved and which they could potentially replace. However, the principle of operation of these two groups of diagnostic devices is substantially different. Thus, an important question arises, regarding the differences in parameters of the transmitted sound and their potential diagnostic consequences in clinical practice...
August 3, 2018: Biomedical Engineering Online
Macartney Welborn, Shelby L Kubicki, Naveen Garg, Anisha B Patel
BACKGROUND AND OBJECTIVES: Tremelimumab is a monoclonal human antibody that inhibits cytotoxic T-lymphocyte-associated antigen 4, giving rise to increased T cell activation and interleukin-2 release. While this activation of the immune system provides a mechanism to recognize and destroy cancer cells, it also leads to off-target immune-related adverse events. Ipilimumab is a US Food and Drug Administration-approved anti-cytotoxic T-lymphocyte-associated antigen 4 antibody, which has a high incidence of cutaneous adverse events...
August 2, 2018: American Journal of Clinical Dermatology
Steven Meyers, Kelly Claire Simon, Stuart Bergman-Bock, Franco Campanella, Revital Marcus, Angela Mark, Thomas Freedom, Susan Rubin, Irene Semenov, Rebekah Lai, Laura Hillman, Samuel Tideman, Anna Pham, Roberta Frigerio, Demetrius M Maraganore
OBJECTIVE: To use the electronic medical record (EMR) to optimize patient care, facilitate documentation, and support quality improvement and practice-based research, in a headache specialty clinic. BACKGROUND: Many physicians enter data into the EMR as unstructured free text and not as discrete data. This makes it challenging to use data for quality improvement or research initiatives. METHODS: We describe the process of building a customized structured clinical documentation support toolkit, specific for patients seen in a headache specialty clinic...
August 1, 2018: Headache
Pei-Fang Lai, Ping-An Wu
The best first-aid treatment for cardiac arrest patients is advanced cardiac life support (ACLS) in terms both of saving lives and of reducing the incidence of sequelae. The American Heart Association (AHA) published updated ACLS guidelines for care in 2015. These updated guidelines emphasized the importance of teamwork in resuscitation, noting that, in addition to standard procedures, team members should be familiar with their distinct roles and should cooperate together during emergent situations. Implementing ACLS is not easy due to stress and unfamiliarity with the process and thus often achieves less-than-optimal results in practice...
August 2018: Hu Li za Zhi the Journal of Nursing
Marianne Turley, Susan Wang, Di Meng, Terhilda Garrido, Michael H Kanter
BACKGROUND: End-of-life care is patient centered when it is concordant with patient preferences. Concordance has been frequently assessed by interview, chart review, or both. These time-consuming methods can constrain sample sizes, precluding population-level quality assessment. Concordance between preferences and care as measured by automated methods is described. METHODS: Automated processes extracted and analyzed electronic health record (EHR) data to assess concordance between 15 advance care planning preference domains and 232 related end-of-life care events for 388 patients aged 65 years or older with an inpatient encounter at Kaiser Permanente Southern California who died during or after the encounter...
July 18, 2018: Joint Commission Journal on Quality and Patient Safety
H M Gunn, M Tsai, A McRae, K S Steinbeck
STUDY OBJECTIVE: Understanding what constitutes a normal menstrual cycle during the first gynaecological year (GY1) is a common concern of adolescents and clinicians. However, limited high-quality evidence exists. We aimed to summarise published literature regarding menstrual and ovulatory patterns in GY1. Design, Setting, Participants and Main Outcome Measures: Electronic databases (MEDLINE, Pre-MEDLINE, Embase, Web of Science, CINAHL, Cochrane Library) were systematically searched from database inception to 2018...
July 28, 2018: Journal of Pediatric and Adolescent Gynecology
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