Composite and comprehensive multimedia electronic health care records

Merged with duplicate record 10026.1/845 on 03.04.2017 by CS (TIS)The thesis considers the issue of multimedia data utilisation within modem health care delivery and the consequent need for an appropriate patient records system. The discussions centre upon the deployment and utilisation of IT systems, and paper-based patient records within health care establishments (HCEs), and the resultant problems, such as data duplication, inconsistency, unavailability and loss. Electronic Health Care Records (EHCRs) are put forward as a means of obviating the problems defined, and effectively supporting the future development of care provision in a coherent manner. The thesis identifies the barriers to further development of EHCRs with respect to clinical data entry, clinical terminiologies, record security and the integration of other information sources. Equally, a number of EHCR developments are reviewed. This shows that, although elements of EHCRs (such as electronic prescribing) have been achieved, significant further developments are required to produce composite and comprehensive EHCRs, capable of capturing and maintaining all patient data (especially multimedia data, which is being increasingly utilised within care provision). The thesis defines a new comprehensive and composite Multimedia Electronic Health Care Record (MEHCR) system to facilitate the following: • delivery and management of all patient care; • creation/recording/support and maintenance of patient data (including multimedia data) to give composite and comprehensive multimedia patient records. The assistance of a local HCE was utilised throughout the project, enabling a suitable reference environment to be established and utilised, so that the process of care provision could be defined. The thesis describes how the requirements of the new MEHCR were identified (via examination of the care provision process defined), and thus how an appropriate conceptual design was formulated. This describes the form and capabilities of the required system. The resulting MEHCR is effectively a comprehensive care provision tool, which aids both process of care delivery and that of data generation and recording. Thus, the MEHCR concept facilitates patient care provision whilst aiding the seamless creation and maintenance of multimedia patient records. To achieve the conceptual design, a design environment was defined to give an intermediate means of enabling the MEHCR's implementation and further development. Thus, the MEHCR can be achieved, or implemented, using either a revolutionary or evolutionary approach. Equally, it is a means for enabling the MEHCR's continued evolution (e.g. the incorporation of new clinical systems etc.), so that it remains composite and comprehensive over time as care provision changes. The thesis also describes an evaluation of the ideas defined, based upon the development of a prototype system simulating the form and operations of the MEHCR conceptual design. The prototype system was demonstrated to a number of parties and an evaluation conducted. The results obtained were very positive as to the nature, structure and capabilities of the system as given by the conceptual design. The design environment was also commended as both a practical means of achieving the MEHCR (especially as it enables retaining of existing system where appropriate), and for its future development as care provision advances.Plymouth Hospitals NHS Trus

The management of medical records in government hospitals: An agenda for reform

Health sector reforms aimed at addressing fundamental problems in health care delivery, and also at preparing the ground for a National Health Service, are currently underway. The reform programme is crucially dependent on improving information flows and information management to facilitate resource planning, monitoring and evaluation. Medical record systems and their management are central to this process, and are here made the subject of review. The emphasis throughout is upon practical solutions that are appropriate to the Ghanaian situation. My purpose is to outline a framework for the development and management of a standardised, coherent medical record system. The state of the art in the creation, maintenance, use and final disposition of medical records is critically reviewed and evaluated with a view to recommending remedial measures and formulating research proposals that could contribute to the improvement of the existing system. The study is limited to selected government-run regional and teaching hospitals (6 in all). For purposes of data collection, the study relied on survey research and adopted the 'records life cycle' concept for its analysis. The study revealed that the problems inherent in the present record systems are due to the absence of sufficiently formalised policies, guidelines and procedures, and to the fact that those that exist are not properly enforced. It is argued that the causes of these deficiencies lie in a lack of accountability and lack of appropriate organisational and managerial structures. A second problem has been the paucity of essential resources; financial, material and human. The study is organised into three sections, each divided into a number of chapters. Section I outlines the context of the study and has three chapters: Introduction, Overview of the Ghana Health Service, and The Medical Record in Historical Perspective. Section II presents the case study and documents the findings of the research (Chapters 4, 5, 6, and 7). A detailed analysis of existing routines and procedures (making comparisons with working methods elsewhere, chiefly English and Scottish hospitals) is presented, painting a picture of the current condition of the function, and providing essential insights regarding the changes required. Section III has two chapters. Chapter 8 recapitulates in brief the key problems discussed in the case study and for which practical solutions are required in order to substantially improve the medical record function. This chapter further proposes solutions to the problems that require intervention at the institutional or operational level, and also to problems which require a strategic approach. Chapter 9 concludes the study and outlines the proposals for reforms presented in Chapter 8

The Electronic Health Record's Impact on Labor and Delivery Nurses' Cognitive Work

The Electronic Health Record’s Impact on Labor and Delivery Nurses’ Cognitive WorkAbstractBackground and objective: Despite recognition that electronic health record (EHR) use has introduced cognitive challenges for clinicians, few studies have evaluated its impact on the cognitive dimension of nurses’ work. Labor and delivery nurses may encounter unique challenges when using the electronic health record since they also interact with an electronic fetal monitoring system. This study sought to explore labor and delivery nurses’ perceptions of the EHR’s impact on their cognitive work with the goal of identifying patient safety implications. Methods and setting: This was a grounded theory study using dimensional and situational analysis. Data were interviews and observations with 21 labor nurses at two community hospitals in the Western United States. Results: The ways that nurses configured care when using the EHR varied across participants and sites and depended on how easily they integrated it into their practice. Individual, group, and situational factors facilitated or constrained integration. This took place in a dynamic, high-acuity, specialty clinical environment while using EHRs that were not designed for pregnant women. Nurses used clinical decision support and other cognitive support features that rarely worked as intended due to the lack of EHR customization to account for pregnancy physiology and unique risk factors in the perinatal patient. Nurses viewed the quality of their relationships with patients and their families as an integral part of caring for laboring women and felt that interaction with the EHR sometimes threatened this dimension of their work. Conclusions: When nurses were unable to integrate the EHR into care it resulted in numerous consequences that have important safety implications. Available cognitive support features lacked the specialty-specific support needed to care for laboring women and instead required nurses to track information in other ways that added to their cognitive burden and work routines. As a result, nurses and patients were not benefitting from the intended decision support and patient safety protections offered by appropriate risk assessment screens or critical alerts. These findings have important implications for the configuration and design of EHRs in perinatal settings

Security management for services that are integrated across enterprise boundaries

This thesis addresses the problem of security management for services that are integrated across enterprise boundaries, as typically found in multi-agency environments. We consider the multi-agency environment as a collaboration network. The Electronic Health Record is a good example of an application in the multi-agency service environment, as there are different authorities claiming rights to access the personal and medical data of a patient. In this thesis we use the Electronic Health Record as the main context. Policies are determined by security goals, goals in turn are determined by regulations and laws. In general goals can be subtle and difficult to formalise, especially across admin boundaries as with the Electronic Health Record. Security problems may result when designers attempt to apply general principles to cases that have subtleties in the full detail. It is vital to understand such subtleties if a robust solution is to be achieved Existing solutions are limited in that they tend only to deal with pre- determined goals and fail to address situations in which the goals need to be negotiated. The task-based approach seems well suited to addressing this. This work is structured in five parts. In the first part we review current declarations, legislation and regulations to bring together a global, European and national perspective for security in health services and we identify requirements. In the second part we investigate a proposed solution for security in the Health Service by examining the BMA (British Medical Association) model. The third part is a development of a novel task-based CTCP ICTRP model based on two linked protocols. The Collaboration Task Creation Protocol (CTCP) establishes a framework for handling a request for information and the Collaboration Task Runtime Protocol (CTRP) runs the request under the supervision of CTCP. In the fourth part we validate the model against the Data Protection Act and the Caldicott Principles and review for technical completeness and satisfaction of software engineering principles. Finally in the fifth part we apply the model to two case studies in the multi- agency environment a simple one (Dynamic Coalition) for illustration purposes and a more complex one (Electronic Health Record) for evaluating the model's coverage, neutrality and focus, and exception handling.EThOS - Electronic Theses Online ServiceArabian Gulf Oil Co.GBUnited Kingdo

November 14, 1978

The Breeze is the student newspaper of James Madison University in Harrisonburg, Virginia

Clinical foundations and information architecture for the implementation of a federated health record service

Clinical care increasingly requires healthcare professionals to access patient record information that may be distributed across multiple sites, held in a variety of paper and electronic formats, and represented as mixtures of narrative, structured, coded and multi-media entries. A longitudinal person-centred electronic health record (EHR) is a much-anticipated solution to this problem, but its realisation is proving to be a long and complex journey. This Thesis explores the history and evolution of clinical information systems, and establishes a set of clinical and ethico-legal requirements for a generic EHR server. A federation approach (FHR) to harmonising distributed heterogeneous electronic clinical databases is advocated as the basis for meeting these requirements. A set of information models and middleware services, needed to implement a Federated Health Record server, are then described, thereby supporting access by clinical applications to a distributed set of feeder systems holding patient record information. The overall information architecture thus defined provides a generic means of combining such feeder system data to create a virtual electronic health record. Active collaboration in a wide range of clinical contexts, across the whole of Europe, has been central to the evolution of the approach taken. A federated health record server based on this architecture has been implemented by the author and colleagues and deployed in a live clinical environment in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. This implementation experience has fed back into the conceptual development of the approach and has provided "proof-of-concept" verification of its completeness and practical utility. This research has benefited from collaboration with a wide range of healthcare sites, informatics organisations and industry across Europe though several EU Health Telematics projects: GEHR, Synapses, EHCR-SupA, SynEx, Medicate and 6WINIT. The information models published here have been placed in the public domain and have substantially contributed to two generations of CEN health informatics standards, including CEN TC/251 ENV 13606

Evaluating individuals with extreme phenotypes of HIV-1 contributes towards better healthcare management of all HIV-1 positive individuals

Human Immunodeficiency Virus (HIV)-1 disease progression is variable within patients where some remain asymptomatic for long periods (elite controllers (EC)) while others rapidly progress to disease (rapid progressors (RP)), representing the ‘extreme phenotypes’. There is substantial heterogeneity in how these phenotypes are defined, and we examined the relative merit of published definitions using data on HIV-1 seroconverters. We propose standard definitions for future research of these rare groups: ECs – maintain consecutive HIV-RNA 500cells/mm3) and high HIV-RNA (>100,000 copies/ml). We contributed towards the ‘what cART to start’ question; among individuals initiating boosted protease inhibitor, atazanavir might be preferable compared to lopinavir, with 30% lower mortality risk, and 9% lower virological failure risk, which could lead to lower transmitted drug resistance (TDR). We found TDR was significantly decreasing throughout Europe, but remains prevalent (8.5% in 2012); therefore, genetic testing among newly diagnosed remains justifiable. For most, starting treatment is a lifelong commitment; however, some report on post treatment control (PTC) upon cART cessation. We found individuals having viral blips on cART had shorter time to viral rebound upon stopping treatment, but most do not become PTC and initiate lifelong cART. We investigated three cART associated toxicities, namely hypersensitivity reactions (HSR) due to abacavir (ABC) utilization, AIDS-defining neurological conditions related to cART, and immune reconstitution inflammatory syndrome (IRIS) shortly after cART initiation. We found that HSR from abacavir utilization is low (Incidence Rate (IR)=1.67/100 person-years follow-up), cART with high central nervous system penetration scores increase HIV-1 dementia risk, and apart from mycobacterial infections, unmasking IRIS may not be a cART complication in high-income countries

Child maltreatment assessment and recidivism : a study of Kentucky child protective services.

This quantitative dissertation examines risk assessment and recidivism of child maltreatment to determine the relationship between child protective services provided by the Kentucky Department of Protection and Permanency and risk of harm. A chart review of existing data on 3,235 closed Kentucky child protective services cases provides information about the quality of service provided to families, the reduction of risk of maltreatment assessed in the family, and the rate of recidivism following case closure. This dissertation examines the usefulness of the Continuous Quality Assessment tool (CQA) and its effectiveness in assessing risk. The CQA is an assessment tool that is designed to guide child protective workers in making case decisions throughout the life of the case. This dissertation on risk assessment and recurrence of maltreatment adds to the measurable outcomes of effectiveness for child protection services and enhances a public child welfare agency\u27s ability to improve service delivery to families. A modified one-group pretest posttest design was utilized to assess the dependent variables, risk of maltreatment and recurrence of maltreatment, before and after casework services were provided. Changes in risk of maltreatment were measured by the cumulative rating on the assessment tool, as well as by scores in the specific risk domains: maltreatment, sequence of events (how well the family is managing their high-risk situations), family development stages, family choice of discipline, adult patterns of behavior, child/youth development, and family support. The second dependent variable, recurrence of maltreatment, was measured by the number of reports of maltreatment investigated in the year following case closure. Findings highlight the success of solution-based casework in creating change. Variables found to be significantly related to reduction in risk include (a)the length of time a case was open for the current treatment episode, (b)region of service, (c)supervisor gender, (d)CQA individual risk domains, and (e)expertise of worker. Variables found to be significantly related to recurrence of maltreatment include (a)CQA safety rating and individual risk domains, (b)worker\u27s level of skill, (c)type of abuse, (d)number of substantiated referrals in case at closure, (e)a prior episode of treatment, and (f)geographic region of service

Secondary use of electronic medical records for early identification of raised condition likelihoods in individuals: a machine learning approach

With many symptoms being common to multiple diseases, there is a challenge in producing an initial diagnosis or recommendation for diagnostic tests from a set of symptoms that could have been produced by a number of diseases. Often the initial choice of diagnosis or testing is based on a clinician’s impression of the likelihood of that condition in a general population; however the opportunity may exist for modification of these likelihoods based on individuals’ recorded medical histories. This data-driven approach utilises existing data and is thus cheap and non-invasive. A method is proposed by which an individual’s likelihoods of having specified medical conditions are modified by the similarity of that individual’s medical history to the medical histories of other individuals, comparing the prevalence of conditions in those other individuals’ records who are similar to the individual of interest versus the prevalence of the conditions in those individuals who are dissimilar. In order to maximise the number of records available for analysis, a process was developed for the merging of data from disparate sources that used different clinical coding systems, including extensive development of a technique for semi automatically mapping clinical events coded in ICD9-CM to Clinical Terms Version 3 (CTV3), for which no existing mapping table was found. Semantically similar fields in the source code sets were identified and retained in the combined data set. ‘Codelists’ comprising multiple CTV3 codes for a variety of conditions were built that defined the presence of those conditions within individual records. The hierarchical structure of the CTV3 code table was utilised as a method of identifying codes that differed in structure but had clinically similar or related meaning. The optimum degree of granularity of the coded data to use in identifying similar records was investigated and used in subsequent analysis. Two methods were used for discovering groups of similar and dissimilar individuals: the ‘nearest neighbours’ method and the grouping of records using a clustering process. Altered likelihoods for a range of conditions were investigated and results for the nearest-neighbours approach compared to the clustering approach. Results for adjusted condition likelihoods for 18 conditions are reported, together with a discussion of possible reasons for a change, or otherwise, in the condition likelihood, and a discussion of the clinical significance and potential use of information about such a change. logistic regressions performed on a selection of conditions KNN performed better than logistic regression when judged by F-score (or sensitivity and specificity separately), however situation more nuanced when looking at likelihood ratios: Logistic regression produced higher (better) positive likelihood ratios, but KNN produced lower (better) negative likelihood ratios. Logistic regression produced higher odds ratios