Standardization of discharge reports with the ISO 13606 norm

Moner, David; Maldonado, José Alberto; Angulo, Carlos; Boscá, Diego; Pérez, Daniel Carvajal; Abad, Irene; Reig, Ernesto; Robles, Montserrat

doi:10.1109/iembs.2008.4649445

Cited by 4 publications

(2 citation statements)

References 4 publications

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“…Discharge summaries (Moner et al 2008) This paper describes a tool, LinkEHR-Ed, used to standardise existing hospital discharge summaries and convert them into archetype format.…”

Section: Disease Surveillancementioning

confidence: 99%

Archetype-Based Electronic Health Records: A Literature Review and Evaluation of Their Applicability to Health Data Interoperability and Access

Wollersheim

Sari

Rahayu

2009

HIM J

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Health Information Managers (HIMs) are responsible for overseeing health information. The change management necessary during the transition to electronic health records (EHR) is substantial, and ongoing. Archetype-based EHRs are a core health information system component which solve many of the problems that arise during this period of change. Archetypes are models of clinical content, and they have many beneficial properties. They are interoperable, both between settings and through time. They are more amenable to change than conventional paradigms, and their design is congruent with clinical practice. This paper is an overview of the current archetype literature relevant to Health Information Managers. The literature was sourced in the English language sections of ScienceDirect, IEEE Explore, Pubmed, Google Scholar, ACM Digital library and other databases on the usage of archetypes for electronic health record storage, looking at the current areas of archetype research, appropriate usage, and future research. We also used reference lists from the cited papers, papers referenced by the openEHR website, and the recommendations from experts in the area. Criteria for inclusion were (a) if studies covered archetype research and (b) were either studies of archetype use, archetype system design, or archetype effectiveness. The 47 papers included show a wide and increasing worldwide archetype usage, in a variety of medical domains. Most of the papers noted that archetypes are an appropriate solution for future-proof and interoperable medical data storage. We conclude that archetypes are a suitable solution for the complex problem of electronic health record storage and interoperability.

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“…Discharge summaries (Moner et al 2008) This paper describes a tool, LinkEHR-Ed, used to standardise existing hospital discharge summaries and convert them into archetype format.…”

Section: Disease Surveillancementioning

confidence: 99%

Archetype-Based Electronic Health Records: A Literature Review and Evaluation of Their Applicability to Health Data Interoperability and Access

Wollersheim

Sari

Rahayu

2009

HIM J

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show abstract

“…The International Classification of Functioning, Disability and Health (ICF), developed by the World Health Organization (WHO) in 2001, mentions HrH and lifestyle as key components of the personal factors of functioning, but does not provide definitions or a classification of these factors. The lack of a preliminary taxonomy impedes both the incorporation of an adequate form of HrH into medical information systems [13,14], and the integration of intervention strategies into both clinical practice and into public health policy. A parallel example showing the importance of health classification systems is the recent development of a taxonomy of medical errors in primary care [15], which allows for the incorporation of related data into systems of health information [16].…”

Section: Introductionmentioning

confidence: 99%

Basic Concepts in the Taxonomy of Health-Related Behaviors, Habits and Lifestyle

Salvador‐Carulla

Alonso²,

Gomez³

et al. 2013

IJERPH

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Background: Health-related Habits (HrH) are a major priority in healthcare. However there is little agreement on whether exercise, diet, smoking or dental hygiene are better described as lifestyles, habits or behaviors, and on what is their hierarchical relationship. This research is aimed at representing the basic concepts which are assumed to constitute the conceptual framework enabling us to interpret and organize the field of HrH. Methods: A group of 29 experts with different backgrounds agreed on the definition and hierarchy of HrH following an iterative process which involved framing analysis and nominal group techniques. Results: Formal definitions of health-related behavior, habit, life-style and life-style profile were produced. In addition a series of basic descriptors were identified: health reserve, capital, risk and load. Six main categories of HrH were chosen based on relevance to longevity: diet/exercise, vitality/stress, sleep, cognition, substance use and other risk. Attributes of HrH are clinical meaningfulness, quantifiability, temporal stability, associated morbidity, and unitarity (non-redundancy). Two qualifiers (polarity and stages of change) have also been described. Conclusions: The concepts represented here lay the groundwork for the development of clinical and policy tools related to HrH and lifestyle. An adaptation of this system to define targets of health interventions and to develop the classification of person factors in ICF may be needed in the future.

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Implementing Structured Clinical Templates at a Single Tertiary Hospital: Survey Study

Hwang¹,

Seoung²,

Lee³

et al. 2020

JMIR Med Inform

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Background Electronic health record (EHR) systems have been widely adopted in hospitals. However, since current EHRs mainly focus on lowering the number of paper documents used, they have suffered from poor search function and reusability capabilities. To overcome these drawbacks, structured clinical templates have been proposed; however, they are not widely used owing to the inconvenience of data entry. Objective This study aims to verify the usability of structured templates by comparing data entry times. Methods A Korean tertiary hospital has implemented structured clinical templates with the modeling of clinical contents for the last 6 years. As a result, 1238 clinical content models (ie, body measurements, vital signs, and allergies) have been developed and 492 models for 13 clinical templates, including pathology reports, were applied to EHRs for clinical practice. Then, to verify the usability of the structured templates, data entry times from free-texts and four structured pathology report templates were compared using 4391 entries from structured data entry (SDE) log data and 4265 entries from free-text log data. In addition, a paper-based survey and a focus group interview were conducted with 23 participants from three different groups, including EHR developers, pathology transcriptionists, and clinical data extraction team members. Results Based on the analysis of time required for data entry, in most cases, beginner users of the structured clinical templates required at most 70.18% more time for data entry. However, as users became accustomed to the templates, they were able to enter data more quickly than via free-text entry: at least 1 minute and 23 seconds (16.8%) up to 5 minutes and 42 seconds (27.6%). Interestingly, well-designed thyroid cancer pathology reports required 14.54% less data entry time from the beginning of the SDE implementation. In the interviews and survey, we confirmed that most of the interviewees agreed on the need for structured templates. However, they were skeptical about structuring all the items included in the templates. Conclusions The increase in initial elapsed time led users to hold a negative opinion of SDE, despite its benefits. To overcome these obstacles, it is necessary to structure the clinical templates for optimum use. In addition, user experience in terms of ease of data entry must be considered as an essential aspect in the development of structured clinical templates.

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Standardization of discharge reports with the ISO 13606 norm

Cited by 4 publications

References 4 publications

Archetype-Based Electronic Health Records: A Literature Review and Evaluation of Their Applicability to Health Data Interoperability and Access

Archetype-Based Electronic Health Records: A Literature Review and Evaluation of Their Applicability to Health Data Interoperability and Access

Basic Concepts in the Taxonomy of Health-Related Behaviors, Habits and Lifestyle

Implementing Structured Clinical Templates at a Single Tertiary Hospital: Survey Study

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