Neste texto apresentam-se os fundamentos, as finalidades e os objectivos que presidem ao dever de documentação dos médicos. Estuda-se o regime de vários ordenamentos jurídicos europeus de acesso ao processo clínico, verificando-se que a maioria das legislações admite o acesso directo do doente ao processo. Relativamente à questão da propriedade do processo clínico, observa-se hoje uma nova compreensão da questão, na medida em que a informação de saúde carece de cautelas suplementares de protecção face aos avanços da genómica, pelo que, em Portugal, a Lei 12/2005, de 26 de Janeiro, outorgou a propriedade da informação de saúde ao paciente, sendo as unidades do sistema de saúde meras depositárias do processo clínico.; This paper discusses the reasons, goals and objectives of the doctor’s duty to register. Secondly, the system of access to medical records in different European countries is analysed. Increasingly the patient has the right to access directly to his/her medical file. Finally, taking into consideration the challenges of genomics, a new perspective of the ownership of medical files is discussed. In that respect, recent Portuguese law (Law 12/2005, 26 January) states that medical information is owned by the patient.; Les fondements...
The objective of this study is to evaluate the entries associated to the sexual function of patients undergoing physical disability rehabilitation, as well as the course of changes and medical approach through a retrospective review of medical charts. Methods: Medical records referring to the period between July and September, 1998 were evaluated. The data was divided into two groups, records containing physician`s entries on sexual function and/or entries of other health care professionals. The following aspects were investigated: whether complaints were spontaneously voiced by the patient, and whether diagnosis had been reached, with corresponding management. Results: Out of 245 medical records investigated, 17 (6.9%) contained clinical observations on the sexual function; out of those, 14 reached diagnosis. Twelve records (4.9%) had information by non-medical healthcare professionals. Out of 17 entries by doctors, 16 referred to male patients, which was found to be significant (p = 0.0202). Conclusions: Records for the sexual function of patients undergoing physical rehabilitation are scarce. In this population, the sexual function of male patients had more extensive investigation on the part of physicians when compared to other health care professionals.
Este trabalho teve o objetivo de analisar o registro dos prontuários hospitalares como subsídio para a gestão em saúde. Foram analisados 430 prontuários de egressos de 2 hospitais públicos municipais de São Paulo internados em abril de 2010. Os resultados mostraram que os registros dos hospitais foram diferentes na maioria das variáveis estudadas, motivo pelo qual foram tratados separadamente. Observou-se que as variáveis sexo, idade, número de diagnósticos, motivo da saída, tempo de permanência e número de cuidados foram totalmente registradas. Enquanto que as variáveis pressão arterial, freqüência cardíaca, freqüência respiratória, temperatura, dor, alimentação, banho e locomoção foram parcialmente registradas. Analisando as variáveis totalmente registradas verificou-se que no Hospital A e B, respectivamente, adultos de 30 a 59 anos (35.9%, 42.3%), idosos com 60 anos ou mais (22.8%, 16.3%) e crianças menores de 4 anos (20.1%, 17.2%) foram os que mais demandaram internações. Da mesma forma, crianças (4 a 5 dias, 4 a 6 dias) e idosos (2 a 6 dias, 4 a 6 dias) necessitaram de maior tempo de permanência. No Hospital A, as doenças do aparelho respiratório (20.5%) foram as principais responsáveis pelas internações...
Delivery of excellent primary care—central to overall medical care—demands that providers have the necessary information when they give care. This paper, developed by the National Alliance for Primary Care Informatics, a collaborative group sponsored by a number of primary care societies, argues that providers’ and patients’ information and decision support needs can be satisfied only if primary care providers use electronic medical records (EMRs). Although robust EMRs are now available, only about 5% of U.S. primary care providers use them. Recently, with only modest investments, Australia, New Zealand, and England have achieved major breakthroughs in implementing EMRs in primary care. Substantial benefits realizable through routine use of electronic medical records include improved quality, safety, and efficiency, along with increased ability to conduct education and research. Nevertheless, barriers to adoption exist and must be overcome. Implementing specific policies can accelerate utilization of EMRs in the U.S.
The Health Insurance Privacy and Portability Act (HIPPA) stipulates that patients must be permitted to review and amend their medical records. As information technology makes medical records more accessible to patients, it may become more commonplace for patients to review their records routinely.
Objective: Patient use of online electronic medical records (EMR) holds the potential to improve health outcomes. The purpose of this study is to discover how patients living with chronic inflammatory bowel disease (IBD) value Internet-based patient access to electronic patient records.
Patients have a legal right under HIPAA to a copy of their medical records. Personal
life-long medical records rely on patients’ ability
to exercise this right inexpensively and in a timely manner. We surveyed 73 hospitals
across the US, with a geographic concentration around
Boston, to determine their policies about fees for copying medical
records and the expected time it takes to fulfill such requests. Fees
range very widely, from $2-55 for short records of 15 pages to $15-585 for
long ones of 500 pages. Times also range widely, from 1–30 days (or longer for off-site records). A few institutions
provide records for free and even fewer make them accessible on-line. We
argue that electronic records will help solve the problem of
giving patients access to their own records, will do so inexpensively
and in a format more likely to be useful than paper.
The medical record has been identified as the source of data for a computerized medical information system. This paper addresses the design of a computerized data base for structuring some of the data normally recorded in the manual medical record. The design identifies the elements of the medical record which constitutes the computerized patient record. A method of transferring the computerized patient record via a low cost magnetic medium at the time the patient is transferred from one health care facility to another is given by the authors. A relatively low cost hardware configuration for the implementation of the computerized patient record for a health care facility is presented.
OBJECTIVE: Identify the lexical content of a large corpus of ordinary medical records to assess the feasibility of large-scale natural language processing. METHODS: A corpus of 560 megabytes of medical record text from an academic medical center was broken into individual words and compared with the words in six medical vocabularies, a common word list, and a database of patient names. Unrecognized words were assessed for algorithmic and contextual approaches to identifying more words, while the remainder were analyzed for spelling correctness. RESULTS: About 60% of the words occurred in the medical vocabularies, common word list, or names database. Of the remainder, one-third were recognizable by other means. Of the remaining unrecognizable words, over three-fourths represented correctly spelled real words and the rest were misspellings. CONCLUSIONS: Large-scale generalized natural language processing methods for the medical record will require expansion of existing vocabularies, spelling error correction, and other algorithmic approaches to map words into those from clinical vocabularies.
Computer-based medical records permit data to be entered into the computer once, coded and stored in a format that does not presuppose a preferred form of retrieval, and displayed in different ways with each display being designed to answer a specific type of question. Experience utilizing the medical record components of the *TMR system in the Nephrology Unit of the Durham Veterans Administration Hospital have shown that problem-oriented, time-oriented, encounter-oriented, and graphical displays of subjective and physical findings, test results, and therapies must be mixed and matched upon demand. The physician user must be able to add and subtract data items from the displays, perform mathematical and statistical calculations based on one or more variables, and vary the time windows upon demand.
The management of incomplete medical records of discharged patients in a manual system typically involves multiple files for medical records and doctors, much paper shuffling and frequent manual searches. A small micro-processor based system was designed and implemented in Z-80 MUMPS and has replaced the manual system in our teaching hospital. It takes only about 20 minutes to train a clerk in its operation since it duplicates the manual system functions quite closely. There has been good acceptance by both the medical staff and the staff of the Medical Records Department.
The Medical Records Department in a large teaching medical center has functional relationships with virtually all other hospital departments. Likewise a computerized system serving that area must anticipate the needs not only of the internal department management, but the interfaces to computer systems serving other areas as well. Such a comprehensive and integrated system was implemented in March, 1981 at the University of California, San Francisco Hospital. Functional modules include medical record tracking, incomplete medical record control, medical transcription for discharge summaries, operative notes and correspondence, and all management statistics. As a vital node in a distributed hospital network, there are links to the hospital patient identification and registration system, the outpatient scheduling system, as well as to the planned operating room system and medical information distribution network. The system is implemented on a Data General Eclipse S/250 using the MIIS operating system.
The increasing availability of electronic medical records offers opportunities to better characterize patient populations and create predictive tools to individualize health care. We determined which asthma patients suffer exacerbations using data extracted from electronic medical records of the Partners Healthcare System using Natural Language Processing tools from the “Informatics for Integrating Biology to the Bedside” center (i2b2). Univariable and multivariable analysis of data for 11,356 patients (1,394 cases, 9,962 controls) found that race, BMI, smoking history, and age at initial observation are predictors of asthma exacerbations. The area under the receiver operating characteristic curve (AUROC) corresponding to prediction of exacerbations in an independent group of 1,436 asthma patients (106 cases, 1,330 controls) is 0.67. Our findings are consistent with previous characterizations of asthma patients in epidemiological studies, and demonstrate that data extracted by natural language processing from electronic medical records is suitable for the characterization of patient populations.
Measuring quality in clinical care is a time-consuming manual task. The vast amounts of clinical data collected through electronic medical records (EMRs) create an opportunity to develop tools that automatically assess quality indicators; however, the diversity of EMR implementations limits the ability to implement general, reusable methods. We evaluate an ontology-based virtual medical record (VMR) approach as a standardized, sharable methodology for defining data abstractions needed for quality of care assessment. Using a set of cancer quality indicators, we conducted a requirements analysis for modeling these abstractions with an OWL-based VMR. We found that the VMR approach needs to be extended to support population-based aggregations of clinical events, models of intended versus completed actions, and models of workflow and delivery systems. Incorporating the patient perspective on quality also requires additional extension of the VMR. We are using these results to create a virtual quality record based on EMR data.
Duplicate medical records occur when a single patient is associated with more than one medical record number. This causes a dangerous and expensive issue for hospitals and health information technology. A survey was constructed to gather qualitative information from Twin Cities healthcare organizations. The goal was to determine baseline information regarding the recognition of the problems surrounding duplicate medical record creation and organizational strategies for resolutions. The survey demonstrated that all organizations acknowledged the importance and patient safety issue regarding the creation of duplicates but the strategies and solutions are varied. As defined in the Minnesota Alliance for Patient Safety5, the ultimate goal of this survey was to favorably impact patient safety. The deidentified results were disseminated to all participating organizations along with recommendations for system improvements in order to raise awareness of the issue and promote patient safety.
This article examines the legal and ethical issues that surround the confidentiality of medical records, particularly in relation to patients who are HIV positive. It records some historical background of the HIV epidemic, and considers the relative risks of transmission of HIV from individual to individual. It explains the law as it pertains to confidentiality, and reports the professional guidance in these matters. It then considers how these relate to HIV-positive individuals in particular.
While Electronic Medical Records (EMR) contain detailed records of the patient-clinician encounter — vital signs, laboratory tests, symptoms, caregivers’ notes, interventions prescribed and outcomes — developing predictive models from this data is not straightforward. These data contain systematic biases that violate assumptions made by off-the-shelf machine learning algorithms, commonly used in the literature to train predictive models. In this paper, we discuss key issues and subtle pitfalls specific to building predictive models from EMR. We highlight the importance of carefully considering both the special characteristics of EMR as well as the intended clinical use of the predictive model and show that failure to do so could lead to developing models that are less useful in practice. Finally, we describe approaches for training and evaluating models on EMR using early prediction of septic shock as our example application.
We propose a mixture model for text data designed to capture underlying structure in the history of present illness section of electronic medical records data. Additionally, we propose a method to induce bias that leads to more homogeneous sets of diagnoses for patients in each cluster. We apply our model to a collection of electronic records from an emergency department and compare our results to three other relevant models in order to assess performance. Results using standard metrics demonstrate that patient clusters from our model are more homogeneous when compared to others, and qualitative analyses suggest that our approach leads to interpretable patient sub-populations when applied to real data. Finally, we demonstrate an example of our patient clustering model to identify adverse drug events.
Mining the free text of electronic medical records (EMR) using natural language processing (NLP) is an effective method of extracting information not always captured in administrative data. We sought to determine if concepts related to homelessness, a non-medical condition, were amenable to extraction from the EMR of Veterans Affairs (VA) medical records. As there were no off-the-shelf products, a lexicon of terms related to homelessness was created. A corpus of free text documents from outpatient encounters was reviewed to create the reference standard for NLP training and testing. V3NLP Framework was used to detect instances of lexical terms and was compared to the reference standard. With a positive predictive value of 77% for extracting relevant concepts, this study demonstrates the feasibility of extracting positively asserted concepts related to homelessness from the free text of medical records.
Being a hospital patient can be isolating and anxiety-inducing. We conducted two experiments to better understand clinician and patient perceptions about giving patients access to their medical records during hospital encounters. The first experiment, a survey of physicians, nurses, and other care providers (N=53), showed that most respondents were comfortable with the idea of providing patients with their clinical information. Some expressed reservations that patients might misunderstand information and become unnecessarily alarmed or offended. In the second experiment, we provided eight hospital patients with a daily copy of their full medical record—including physician notes and diagnostic test results. From semi-structured interviews with seven of these patients, we found that they perceived the information as highly useful even if they did not fully understand complex medical terms. Our results suggest that increased patient information sharing in the inpatient setting is beneficial and desirable to patients, and generally acceptable to clinicians.