Transition to a Computer-Based Record Using Scannable, Structured Encounter Forms

Shiffman, Richard N.; Brandt, Cynthia; Freeman, Bruce G.

doi:10.1001/archpedi.1997.02170490073013

Cited by 25 publications

(22 citation statements)

References 6 publications

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“…11,[19][20][21][22] Both improved training and standardized medical record forms, which prompt physicians on age-appropriate advice, might help. 23 Incorporating anticipatory guidance into quality assessment systems would create additional incentives for physicians and health care organizations to deliver guidance. [24][25][26] Second, physicians may not be confident that their advice will be useful.…”

Section: Possible Reasons Anticipatory Guidance Is Not Providedmentioning

confidence: 99%

Anticipatory Guidance

Schuster

Duan²,

Regalado³

et al. 2000

Arch Pediatr Adolesc Med

162

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Section: Possible Reasons Anticipatory Guidance Is Not Providedmentioning

confidence: 99%

Anticipatory Guidance

Schuster

Duan²,

Regalado³

et al. 2000

Arch Pediatr Adolesc Med

162

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“…9,10,27,28 Evidence for their effect on outcomes is sparse. 15,29 Data Standards and Equity Data standards can have 2 basic effects on equity in the health care system, that is, ensuring that information systems provide the same levels of benefits to all populations (via functional standards) and making regional health data interchange networks possible (via messaging and terminology standards).…”

Section: Data Standards and Effectivenessmentioning

confidence: 99%

Data Standards and Improvement of Quality and Safety in Child Health Care

Spooner

Classen

2009

Pediatrics

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Progress in using information technology to achieve the goal of high-quality health care is hindered by the lack of coordinated data standards. To accelerate quality improvement in pediatrics, child health providers must participate actively in the creation of health care data standards. To do so will require far greater understanding on the part of pediatricians and other pediatric providers regarding the scope and role of data standards in advancing health information systems for children, as well as how data standards could improve quality in child health, what kinds of data standards hold the most promise for quality improvement in child health, and how child health professionals can engage in the work of creating data standards. Child health professionals in organized and academic medicine should participate in standards development organizations, to present the pediatric point of view as data standards emerge. They also should support efforts to certify electronic health record systems that include pediatric functionality. A major challenge to academic pediatrics is to prove that data standards can lead to improved health outcomes for children; this is only a compelling conjecture as of this writing. Pediatrics 2009;123:S74-S79 T HE INSTITUTE OF Medicine specifies 6 attributes of quality in health care, namely, safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability. 1 The medical community broadly accepts that information technology (IT) and health care information systems will play an important role in implementing and measuring these quality attributes. 2,3 Progress in using IT to achieve these ends is hindered, however, by the lack of coordinated data standards. 4 To accelerate quality improvement in pediatrics, child health providers must participate actively in the creation of health care data standards. In this report, we describe how data standards could improve quality in child health, what kinds of data standards hold the most promise for quality improvement in child health, and how child health professionals can engage in the work of creating data standards. TYPES OF HEALTH CARE DATA STANDARDSStandards exist to allow people in different roles or in different institutions to cooperate efficiently and effectively. For example, because electrical outlets in a given country are standardized, different manufacturers can produce appliances that work in every home. In health care, a standard definition of acute lymphoblastic leukemia assists practitioners in providing similar care to patients in different health care facilities. Time and energy do not need to be expended in converting electrical plugs or redefining acute lymphoblastic leukemia staging, because these standards have been accepted by a wide range of individuals.There are 3 types of data standards that influence health care IT, that is, terminology standards, messaging standards, and functional standards. Terminology standards specify which terms are to be used in a particular clinical domain and how e...

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“…Typing with keyboards has itself its own limitations, and reuse of pre-saved sentences or copyand-pasting other parts of the record are major sources of errors in the EMR (Hammond et al 2003). In order to overcome these problems, some EMRs have used a Research structured data entry system for the interim history, risk assessment, developmental screening and guidance sections of the record, which has resulted in better documentation in the EMR when compared with the PMR (Adams, Mann & Bauchner 2003;Johnson & Cowan 2002;Shiffman, Brandt & Freeman 1997;Bauchner Kanegaye et al 2005). However, the patient's chief complaint and present illness were freely documented in the legacy PMR and were recorded with narrative text rather than the structured data as seen in the EMR.…”

Section: Introductionmentioning

confidence: 99%

A Study of the Difference in Volume of Information in Chief Complaint and Present Illness between Electronic and Paper Medical Records

Boo

Noh

Kim

et al. 2012

HIM J

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The introduction of an electronic medical record (EMR) has been rapidly accelerating in South Korea. The EMR was expected to improve quality of care, readability, availability, and the quality of data. However, the reluctance of healthcare providers to use the EMR may have caused a reduction of information recorded in EMRs. The purpose of this study was to identify whether there was any loss of information following the introduction of a narrative text-based EMR in the recording of chief complaint and present illness in inpatient medical records. Inpatient medical records of a university hospital were retrospectively evaluated for one month before and one month after the introduction of the EMR in June 2006. The volume of information for chief complaint and present illness was measured by number of words in Korean and normalised bytes. Change in volume of information was measured by two-way ANOVA and multiple regression analyses, controlling for doctors' gender, age, and grade/year of residents, patients' readmission status, reasons for admission and service department to assess any effect of the introduction of an EMR. Total numbers of paper-based medical records (PMRs) and EMRs for analysis were 1,159 and 1,122, respectively. Forty-three doctors participated in the study. Thirty-one (72%) doctors were less than 30 years of age. Number of words proved a better outcome measure (R²=22 for CC, R²=36 for PI) than normalised bytes (R²=18 for CC, R²=35 for PI) for measuring volume of information. Results showed that the volume of information in the chief complaint and present illness was not decreased after the introduction of the EMR, except when the dependent variable was measured by number of words in the present illness. The study showed that the introduction of the EMR did not reduce the volume of information documented for chief complaint and present illness in inpatient medical records. However, further studies are needed to identify how to control the probable loss of information as showed in present illness measured by number of words.

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Transition to a Computer-Based Record Using Scannable, Structured Encounter Forms

Cited by 25 publications

References 6 publications

Anticipatory Guidance

Anticipatory Guidance

Data Standards and Improvement of Quality and Safety in Child Health Care

A Study of the Difference in Volume of Information in Chief Complaint and Present Illness between Electronic and Paper Medical Records

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