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The Malaysian Journal of Pathology Aug 2022No abstract available.
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Applied Clinical Informatics Jan 2022Providing patients with medical records access is one strategy that health systems can utilize to reduce medical errors. However, how often patients request corrections...
BACKGROUND
Providing patients with medical records access is one strategy that health systems can utilize to reduce medical errors. However, how often patients request corrections to their records on a national scale is unknown.
OBJECTIVES
We aimed to develop population-level estimates of patients who request corrections to their medical records using national-level data. We also identified patient-level correlates of requesting corrections.
METHODS
We used the 2017 and 2019 Health Information National Trends Survey and examined all patient portal adopters. We applied jackknife replicate weights to develop population-representative estimates of the prevalence of requesting medical record corrections. We conducted a multivariable logistic regression analysis to identify correlates of requesting corrections while controlling for demographic factors, health care utilization patterns, health status, technology/internet use patterns, and year.
RESULTS
Across 1,657 respondents, 125 (weighted estimate: 6.5%) reported requesting corrections to their medical records. In unadjusted models, greater odds of requesting corrections were observed among patients who reported their race/ethnicity as non-Hispanic black (odds ratio [OR]: 2.20, 95% confidence interval [CI]: 1.10-4.43), had frequent portal visits (OR: 3.92, 95% CI: 1.51-10.23), and had entered data into the portal (OR: 7.51, 95% CI: 4.08-13.81). In adjusted models, we found greater odds of requesting corrections among those who reported frequent portal visits (OR: 3.39, 95% CI: 1.24-9.33) and those who reported entering data into the portal (OR: 6.43, 95% CI: 3.20-12.94). No other significant differences were observed.
CONCLUSION
Prior to the Information Blocking Final Rule in April 2021, approximately 6.5% of patients requested corrections of errors in their medical records at the national level. Those who reported higher engagement with their health, as proxied by portal visit frequency and entering data into the portal, were more likely to request corrections.
Topics: Electronic Health Records; Humans; Medical Errors; Patient Portals; Prevalence; Surveys and Questionnaires
PubMed: 35196717
DOI: 10.1055/s-0042-1743236 -
Clinical Medicine (London, England) 2003Medical records serve many functions but their primary purpose is to support patient care. The RCP Health Informatics Unit (HIU) has found variability in the quality of... (Review)
Review
Medical records serve many functions but their primary purpose is to support patient care. The RCP Health Informatics Unit (HIU) has found variability in the quality of records and discharge summaries in England and Wales. There is currently a major drive to computerise medical records across the NHS, but without improvement in the quality of paper records the full benefits of computerisation are unlikely to be realised. The onus for improving records lies with individual health professionals. Structuring the record can bring direct benefits to patients by improving patient outcomes and doctors' performance. The HIU has reviewed the literature and is developing evidence-based standards for record keeping including the structure of the record. The first draft of these standards has been released for consultation purposes. This article is the first of a series that will describe the standards, and the evidence behind them.
Topics: Forms and Records Control; Guidelines as Topic; Humans; Medical Audit; Medical Records; Outcome and Process Assessment, Health Care; United Kingdom
PubMed: 12938746
DOI: 10.7861/clinmedicine.3-4-329 -
Anales Del Sistema Sanitario de Navarra 2011Confidentiality is a key aspect in the relationship between health professionals and patients. It involves the cession by the patient of a reserved part of herself and... (Review)
Review
Confidentiality is a key aspect in the relationship between health professionals and patients. It involves the cession by the patient of a reserved part of herself and the ethical principles of autonomy and non-maleficency that are closely linked to its preservation. There are also numerous legal regulations that make professional secrecy obligatory, in some cases imposing hard sanctions that are often not known about. As the medical record is the document where the relationship with the patient is recorded, it requires extraordinary protection due to the especially sensitive nature of the information it contains. It should be compulsory that the professional who works with it should know some basic aspects of the fundamental laws that regulate it in different aspects. This article reviews questions that at times are only known in the abstract, but that are contained in the legal regulations, such as ownership of the medical record, subjective annotations, its custody and rectification or who can have access to it and why.
Topics: Confidentiality; Medical Records
PubMed: 21532648
DOI: 10.4321/s1137-66272011000100008 -
BMC Medical Informatics and Decision... Mar 2018De-identification is the first step to use these records for data processing or further medical investigations in electronic medical records. Consequently, a reliable...
BACKGROUND
De-identification is the first step to use these records for data processing or further medical investigations in electronic medical records. Consequently, a reliable automated de-identification system would be of high value.
METHODS
In this paper, a method of combining text skeleton and recurrent neural network is proposed to solve the problem of de-identification. Text skeleton is the general structure of a medical record, which can help neural networks to learn better.
RESULTS
We evaluated our method on three datasets involving two English datasets from i2b2 de-identification challenge and a Chinese dataset we annotated. Empirical results show that the text skeleton based method we proposed can help the network to recognize protected health information.
CONCLUSIONS
The comparison between our method and state-of-the-art frameworks indicates that our method achieves high performance on the problem of medical record de-identification.
Topics: Data Anonymization; Electronic Health Records; Humans; Neural Networks, Computer
PubMed: 29589571
DOI: 10.1186/s12911-018-0598-6 -
BMJ Open Aug 2018Inadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify...
OBJECTIVE
Inadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify transitional safety incidents (TSIs) for use in a large intervention study and assess its reliability and validity.
DESIGN
A retrospective medical record review study.
SETTINGS AND PARTICIPANTS
Combined primary and secondary care medical records of 301 patients who had visited their general practitioner and the University Medical Center Utrecht, the Netherlands, in 2013 were randomly selected. Six trained reviewers assessed these medical records for presence of TSIs.
OUTCOMES
To assess inter-rater reliability, 10% of medical records were independently reviewed twice. To assess validity, the identified TSIs were compared with a reference standard of three objectively identifiable TSIs.
RESULTS
The reviewers identified TSIs in 52 (17.3%) of all transitional medical records. Variation between reviewers was high (range: 3-28 per 50 medical records). Positive agreement for finding a TSI between reviewers was 0%, negative agreement 80% and the Cohen's kappa -0.15. The reviewers identified 43 (22%) of 194 objectively identifiable TSIs.
CONCLUSION
The reliability of our measurement tool for identifying TSIs in transitional medical record performed by clinicians was low. Although the TSIs that were identified by clinicians were valid, they missed 80% of them. Restructuring the record review procedure is necessary.
Topics: Adult; Aged; Aged, 80 and over; Electronic Health Records; Female; Humans; Male; Medical Audit; Medical Errors; Medical Record Linkage; Middle Aged; Observer Variation; Patient Safety; Primary Health Care; Reproducibility of Results; Retrospective Studies; Secondary Care; Transitional Care; Young Adult
PubMed: 30104308
DOI: 10.1136/bmjopen-2017-018576 -
BMC Medical Education Nov 2021Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note...
BACKGROUND
Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants' medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications.
METHODS
The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated the EMRs using a checklist. Medical records were grouped as general medicine, surgery, paediatric, obstetrics and gynaecology, and other departments. The overall and group performances were analysed using analysis of variance (ANOVA).
RESULTS
Overall performance was rated as fair to good. Regarding the six note types, discharge notes (0.81) gained the highest scores, followed by admission notes (0.79), problem list (0.73), overall performance (0.73), progress notes (0.71), and weekly summaries (0.66). Among the five groups, other departments (80.20) had the highest total score, followed by obstetrics and gynaecology (78.02), paediatrics (77.47), general medicine (75.58), and surgery (73.92).
CONCLUSIONS
This study suggested that duplication in medical notes and the documentation abilities of residents affect the quality of medical records in different departments. Further research is required to apply the insights obtained in this study to improve the quality of notes and, thereby, the effectiveness of resident training.
Topics: Child; Documentation; Electronic Health Records; Humans; Internship and Residency; Medical Records; Physicians; Writing
PubMed: 34774027
DOI: 10.1186/s12909-021-03011-0 -
Social Science & Medicine (1982) Jan 2022With patients' increasing online access to medical information traditionally contained within healthcare institutions, researchers have argued that the spaces of...
With patients' increasing online access to medical information traditionally contained within healthcare institutions, researchers have argued that the spaces of medicine are increasingly becoming blurred, allowing patients to sidestep their doctors and challenge their prior information dominance. In this context, Sweden has recently been spotlighted as it allows its inhabitants to continually access medical record content online. Based on an interview study on Swedish doctors' clinical experiences of the patient-accessible online health record, this paper expands on the theme of emergent medical information spaces accessible to laypersons online by arguing that this not only may challenge the traditional spaces of medicine but can impose on its temporal orders too. We detail doctors' attitudes toward the patient-accessible online health record, patients as continually updated record readers, and how this may transform clinical work rhythms and affect doctors' perceptions of the boundary between front- and backstage spaces. We moreover show how doctors can avoid "inappropriate intrusion" into the record by delaying patient access, but also that doctors can experience patients opposing to adapt to doctors' preferred pace and instead attempting to control the clinical rhythm. By intertwining clinical rhythms with doctors' front- and backstage, this paper contributes with an extended analysis of the emergent spaces of online medical information, adding a temporal layer. The paper furthermore enlarges the existing sociological body on historical developments of medical records and adds a piece to the so-far piecemeal social science literature on how online records may affect the medical profession.
Topics: Attitude; Attitude of Health Personnel; Health Records, Personal; Humans; Physicians; Sweden
PubMed: 34891029
DOI: 10.1016/j.socscimed.2021.114635 -
Revista de Saude Publica Oct 2009To analyze both national and international literature on validity of record linkage procedure of health databases focusing on quality assessment of results. (Review)
Review
OBJECTIVE
To analyze both national and international literature on validity of record linkage procedure of health databases focusing on quality assessment of results.
METHODS
A systematic review of cohort, case-control, and cross-sectional studies that evaluated quality of probabilistic record linkage of health databases was conducted. Cochrane methodology of systematic reviews was used. The following databases were widely searched: Medline, LILACS, Scopus, SciELO and Scirus. A time filter was not applied and articles were searched in the following languages: Portuguese, Spanish, French and English.
RESULTS
Summary measures of the quality of probabilistic record linkage were sensitivity, specificity, and positive predictive value. There were identified 202 studies, and after applying the inclusion criteria, a total of 33 articles were reviewed. Only six had complete data on the summary measures of interest. The main limitations were: no reviewer to evaluate titles and abstracts; and no blinding of the article's authors in the review process. Most scientific publications in this field were from the United States, United Kingdom, and New Zealand. Overall, the accuracy of probabilistic record linkage of databases ranged from 74% to 98% sensitivity and 99% to 100% specificity.
CONCLUSIONS
Probabilistic record linkage of health databases has notably been characterized by high sensitivity and greater flexibility of the procedure's sensitivity, indicating concern with data accuracy. The positive predictive value in studies shows a high proportion of truly positive record pairs. The quality assessment of these procedures has been proved essential for validating the results obtained in these studies, and can also contribute to improve large health databases available in Brazil.
Topics: Biomedical Research; Databases, Factual; Medical Record Linkage; Medical Records Systems, Computerized; Sensitivity and Specificity
PubMed: 19784456
DOI: 10.1590/s0034-89102009005000060 -
BMC Medical Informatics and Decision... Aug 2016A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient... (Review)
Review
BACKGROUND
A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR). Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR.
METHODS
On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements.
RESULTS
In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability.
CONCLUSIONS
Two main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.
Topics: Electronic Health Records; Health Plan Implementation; Humans; Medical Records, Problem-Oriented
PubMed: 27485127
DOI: 10.1186/s12911-016-0341-0