Development of a Minimum Data Set (MDS) for C-Section Anesthesia Information Management System (AIMS)

Development and evaluation of an anesthesia module for electronic medical records in the operating room: an applied developmental study

Developing an anesthesia module in the operating room is one of the significant steps toward the implementation of electronic medical records (EMR) in health care centers. This study aimed to develop and evaluate the web based-anesthesia module of an electronic medical record Sciences, in the operating room of the Namazi Medical Training Center of Shiraz University of Medical Iran. This developmental and applied study was conducted in steps including determining the functional and non-functional requirements, designing and implementing the anesthesia module, and usability evaluation. 3 anesthesiologists, 3 anesthesiologist assistants, and 12 anesthetist nurses were included in the study as a research community. React.js, Node.js programming language to program this module, Mongo dB database, and Windows server for data management and USE standard questionnaire were used. In the anesthesia module, software quality features were determined as functional requirements and non-functional requirements included 286 data elements in 25 categories (demographic information, surgery information, laboratory results, patient graphs, consults, consent letter, physical examinations, medication history, family disease records, social record, past medical history, type of anesthesia, anesthesia induction method, airway management, monitoring, anesthesia chart, blood and fluids, blood gases, tourniquets and warmers, accessories, positions, neuromuscular reversal, transfer the patient from the operating room, complications of anesthesia and, seal/ signature). Also, after implementing the anesthesia module, results of the usability evaluation showed that 69.1% of the users agreed with the use of this module in the operating room and considered it user-friendly.

Designing a minimum data set for the information management system (registry) of spinal canal stenosis: An applied-descriptive study

Background and Aims

Spinal canal stenosis is one of the most common vertebral column diseases, which can lead to disability. Developing a registry system can help in research on the prevention and effective treatment of it. This study designs a minimum data set (MDS) as the first step in creating a registry system for spinal canal stenosis.

Method

The present research is of applied-descriptive type, performed in 2022. First, the applicable data elements about the disease were selected from a vast range of English and Farsi references, including peer reviewed articles, academic books, credible websites, and medical records of hospitalized patients. Through the extracted data, the primary MDS plan was designed as a questionnaire. The validity of the questionnaire was conducted via asking the opinion of experts (neurosurgeons, physiotherapists, epidemiologists, and health information management specialists). Also, its reliability was calculated via Cronbach ⍺ coefficient, which was 86%. Finally, the MDS of the spinal canal stenosis national registry system (for Iran) was confirmed through a two stage Delphi technique. Data analysis was applied through descriptive statistics via SPSS21 software.

Results

The proposed MDS is offered in two general sets of data: administrative and clinical. For the administrative data set, 40 data elements had been proposed, as five classes. Twenty-six of them were confirmed. In the clinical section, 95 data elements had been proposed in 14 classes; 94 of which were finally confirmed.

Conclusion

Since there is no spinal canal stenosis MDS available, this study can be a turning point in the standardization of the data on this disease. Moreover, these precise, coherent, and standard data elements can be contributed to improving disease management and enhancing the public healthcare quality. Also, the MDS proposed in this study can help researchers and experts, design a spinal canal stenosis registry system in other countries.

Identification of Minimum Data Set of Neonatal Prematurity Information Management System for Iran

The Article Abstract is not available.  

Designing the minimum data set of bipolar disorder: A basis for introducing the effective factors in managing, controlling, and monitoring the bipolar disorder

BACKGROUND AND AIM

Bipolar disorder (BD) is one of the most challenging psychiatric disorders in the management area that can lead to functional, occupational, and cognitive disorders. Without proper care, this complication can lead to profound psychological challenges and even death. The aim of this study is to design a minimum data set (MDS) for BD.

MATERIALS AND METHODS

This descriptive cross-sectional study was conducted in two steps. In the first step, a survey was conducted in PubMed, Web of Science, and SCOPUS databases to identify the demographic, managerial, and clinical data elements. Then, the required data elements were extracted from the studies by the data extraction form and used in a questionnaire. In the second step, to confirm the data element set, the designed questionnaire was distributed and collected among 20 psychiatrists and subspecialists during a two-stage Delphi technique. Descriptive statistics (frequency and mean) were conducted to analyze the data.

RESULTS

Totally, 112 managerial and clinical data elements in 14 categories were extracted from the studies. Based on the experts' opinion and their consensus, 88 necessary data elements were considered to bipolar MDS. "Medication nonadherence," "history of suicide," and "substance abuse and addiction" were the most important data elements.

CONCLUSION

In this study, an MDS was designed for BD. Providing this MDS, in addition to improving the clinical processes, it is possible to help electronic system designers and health data managers to know what information should be included in the health systems or any kind of self-care or self-management software to meet the information needs of these patients.

Developing a National Minimum Data Set for Kawasaki Disease Registry in Iran

BACKGROUND

Kawasaki Disease is an acute and self-limited systemic inflammatory and febrile illness, which is the most common cause of acquired heart disease in children in developed countries. The incidence of KD in Asian countries is high. But, data is not available from the Middle East. So, the aim of this study was to develop an MDS to set up a national registry for KD to estimate the burden of disease in Iran.

MATERIALS AND METHODS

This cross-sectional and descriptive study was conducted in 2020. Literature review, data collection from patients medical records, and expert panel approach were used to design this MDS. Data elements with a Content Validity Ratio (CVR) of more than 0.56 were selected as the MDS of the registry.

RESULTS

Overall, 99 data elements were recognized. Of which, 51 and 48 data elements were verified and rejected, respectively. Moreover, 17 data elements were added as required by experts. Eventually, 68 data elements were chosen as the MDS of the national KD registry of IRAN; of which, 17 and 51 data elements were classified as administrative and clinical data, respectively.

CONCLUSIONS

These precise, integrated, and comprehensive developed data elements and the national KD registry will lead to effective disease management and thus, improve the quality of care and, consequently, improve public health.

Identification of the minimum data set to design a mobile-based application on overweight and obesity management for children and adolescents

PURPOSE

Designing mobile-based applications is one of the tools to raise the awareness of patients and the care team. Aim of this study is to identify the data elements of a mobile-based application to overweight and obesity management for children and adolescents from the experts' point of view.

METHODS

In this descriptive-analytical article, data collection was conducted through library and Internet research. The research population comprised 30 nutritionists selected via simple sampling method. The research instrument was a questionnaire developed by the researcher in four sections: demographic data, assessment data, therapeutic recommendations and application capabilities. Validity and reliability were confirmed by Content Validity Ratio (CVR) and Delphi method respectively.

RESULTS

The Minimum Data Set (MDS) required for overweight and obesity management in children and adolescents was designed based on the data from the guidelines of the United States, Canada, Australia, Britain, Iran, and experts' opinions. The importance of this MDS suggested was calculated based on the percentage points given by experts for the demographic data of 100%, the assessment data of 88.33%, the therapeutic recommendations of 97.67%, and the application capabilities of 88.94%.

CONCLUSION

Identifying prevention and control minimum data set of overweight and obesity in children and adolescents from the point of view of experts will be effective in improving the applications in this field. This MDS has two parts of data elements: the first for recognition of the framework of evaluating and applying therapeutic methods that can empower parents to manage the child's body mass and the second as a patient's personal record for storage a set of data that can be used by nutritionists in visits to healthcare centers.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-021-00807-1.

Development and validation of the Neonatal Abstinence Syndrome Minimum Data Set (NAS-MDS): a systematic review, focus group discussion, and Delphi technique

OBJECTIVES

Neonatal abstinence syndrome (NAS) is a combination of symptoms in infants exposed to any variety of substances in utero. Information systems and registries help to collect information about these patients; however, there is always a deep gap between complete and accurate information to be collected, understood, and applied in the health care system; thus, defining a minimum data sets (MDS) as one of the primarily steps of designing a registry system is essential. The aim of this study was to develop an MDS of the registry for infants with NAS in Iran.

METHODS

This research is a descriptive cross-sectional study. In this study, three steps were carried out to develop the MDS including systematic review, Delphi technique, and focus group discussion. A systematic review was conducted in relevant databases to identify appropriate related data. In the second phase, a focus group discussion was used to classify the extracted data elements by contributing neonatologists. Finally, data elements were chosen through the decision Delphi technique in two distinct rounds. Collected data were analyzed using SPSS 22 (SPSS Inc., Chicago, IL).

RESULTS

By reviewing related papers and available NAS registries in other countries, 145 essential data elements were identified. They were classified into two main categories based on the eight experts' opinions including maternal with two sections and infant with two sections. After applying two rounds of Delphi technique, the final data elements for maternal and infant categories were 42 and 31, respectively. Thus, on completion of the survey, 73 data elements were approved.

CONCLUSION

The proposed MDS for NAS can help to store an accurate and comprehensive data, document medical records, integrate them with other information systems and registries, and communicate with other healthcare providers and healthcare centers. This MDS can contribute to the provision of high-quality care and better clinical decisions.

A minimum data set of user profile or electronic health record for chemical warfare victims' recommender system

Background:

There are many people who are suffering from a variety of physical and mental illnesses due to the chemical attacks. There are various technologies such as recommender systems that can identify the main concerns related to health and make efforts to address them. To design and develop a recommender system, preparation of data source of this system should be considered. The aim of this study was to determine the minimum data set for user profile or user's electronic health record in chemical warfare victims’ recommender system.

Methods:

This applied descriptive, cross-sectional study which was conducted in 2017. A questionnaire was developed by the authors from the data elements that were collected using the data extraction form from the studied sources. Content validity of the questionnaire was confirmed by using the experts. Test–retest method was used to determine the reliability of the questionnaire. The reliability of the questionnaire with Cronbach's alpha coefficient was confirmed as 84%. The questionnaire were submitted for related experts based on Delphi method by email or in person. Data resulting from the Delphi technique with descriptive statistics methods in SPSS software were analyzed.

Results:

Forty-seven nonclinical data elements and 181 clinical data elements were classified.

Conclusion:

Determining minimum data set of user profile or electronic health record in the recommender system for chemical warfare victims helps the health authorities to implement the recommender system which demonstrates chemical warfare victims’ needs.

Development a national minimum data set for poisoning registry in Iran

OBJECTIVES

In the developing countries with high mortality rates, poisoning is considered to be one of the most common causes of admission to emergency wards. Given the importance of registering data on poisoned patients, it is very important to have a complete poisoning Minimum Data Set (MDS). Therefore, the purpose of this study was to determine an MDS for poisoning registry in Iran.

METHODS

This applied and cross-sectional study was conducted through of Delphi technique in the poisoning ward of Imam Reza Hospital (northeastern Iran) in 2019. Literature reviews were initially carried out on such databases as PubMed, Web of Sciences, Scopus, and Embase. Then, Google search was done to retrieve poisoning forms and poisoning registry websites. Also, we considered International Classification of Diseases, 10th Revision coding guidelines of poisoning. Then, a questionnaire containing data elements of poisoning was developed.

RESULTS

In total, 558 data elements were developed during two rounds of Delphi technique. The MDS was divided into 10 categories including patient and communication data, encounter data, diagnostic data and medical history, exposure data, clinical data, treatment data, complications, paraclinical tests, biobank, and discharge data.

CONCLUSIONS

Establishing an MDS as the first and most important step towards implementing poisoning registry can be the standard basis for collecting poisoned patient data. The data registered in the poisoning registry can be used for planning, policy-making, prevention, and control purposes.

Better monitoring of abused children by designing a child abuse surveillance system: Determining national child abuse minimum data set

BACKGROUND

Monitoring the trend of child abuse can significantly help in measuring the magnitude of the problem and understanding its recurrence. The minimum data set (MDS) is a set of elements of each domain that provides the basis for decision-making. This study was conducted to determine the comprehensive national minimum data set for child abuse surveillance system (CASS) in Iran.

METHODS

This is a cross-sectional descriptive study. Data were gathered from the selected countries and child abuse registry and surveillance systems. The MDS questionnaire was designed based on a review of the publications and experts' opinions. The final data elements of the CASS were determined using the Delphi technique by visiting pediatricians.

RESULTS

In total, 147 data elements were included in the Delphi survey. The data elements of the CASS were classified into seven categories as follows: demographic data, incident related data, medical history, diagnostic tests, incident nature, therapeutic measures, and other required data.

CONCLUSION

The existence of national MDS as the core of the child abuse surveillance program is essential and leads to appropriate decisions in this regard. The MDS can meet the needs of professionals, decision makers, researchers, and policymakers who decide on reducing the incidence of child abuse.

Data Requirements for Information Management System Development for Poisoning with Acidic and Alkaline Substances

Introduction:

Ingestion of acidic or alkaline substances and its long-term effects on digestive system indicates is a common health problem worldwide. To identify the root causes of injuries, standard data collection is required.

Aim:

The present study was conducted to determine the data requirements for the establishment of information management system for poisoning with acidic and alkaline substances in Iran.

Methods:

This is a descriptive and cross-sectional study conducted in 2017. First, we attended at the hospitals affiliated to Iran, Tehran and Shahid Beheshti universities of medical sciences, which had poisoning wards; we studied all forms, reports and medical records of people who had been poisoned by acidic or alkaline substances. In the next step, a comprehensive literature review was carried out to retrieve related resources. Data were collected using data extraction form and Delphi method was used to survey them. Validity of the questionnaire was evaluated through content validity and its reliability checked by the test-retest method and Cronbach’s alpha.

Results:

A minimum data set (MDS) of alkaline and acid poisoning divided into two categories: administrative with three classes including 35 data elements, and clinical with 6 classes including 145 data elements.

Conclusion:

Comprehensive and uniform data elements about alkaline and acid poisoning was not available in Iran. Development of a MDS resulted in standardization and effective management of the data through providing uniform and comprehensive data elements for alkaline and acid poisoning and comparability of information in various levels and made effective decision-making and policy-making possible.

Design of Infertility Monitoring System: Minimum Data Set Approach

Reproductive health is vital for human and infertility is also one of the most important challenges in the reproductive system. Infertility is one of the most common chronic health disorders, regardless of age. The Minimum Data Set (MDS) helps to manage infertility by monitoring and evaluating infertility interventions based on collecting data.

The development of MDS is an essential objective in order to implement an infertility monitoring system for the creation of standardized and effective data management through the provision of comprehensive and identical data elements for infertility.

This is a descriptive cross-sectional study conducted in 2017. The data has been collected from infertility clinics in the world, as well as WHO, CDC, ASRM, and ESHRE reports.

In order to decide on data elements, the Delphi technique was used using a questionnaire that contained data elements which were distributed among 12 experts including one reproductive endocrinology and infertility fellow, six obstetrician-gynecologists, two reproductive biologists, two urologists and one community medicine specialist using the 5 point Likert scale. The questionnaire was divided into two categories: managerial and clinical, each with 4 sections, and 60 and 940 data elements, respectively.

MDS is an essential tool for evaluating the infertility process. Using this tool will provide an opportunity to develop a set of quality care criteria that can be used to ensure the quality of infertility care.

Speaking the same language: Development of a Nutrition Minimum Data Set for healthcare professionals in primary healthcare

Providing the best possible nutritional care requires accurate and precise communication between healthcare professionals. Developing a Nutrition Minimum Data Set will inform professionals in primary healthcare of which core elements should be documented and facilitate a standardized approach to the documentation of nutritional care. A two-step methodological approach was utilized in this study: (1) a systematic scoping review was conducted to map evidence underpinning the development of a Minimum Data Set and (2) the datasources were categorized using the inductive content analysis approach. A total of 32 items were identified in the datasources. Five categories were inductively derived from the data: (1) physiologic measurements, (2) ability to eat, (3) intake, (4) stress factors and (5) factors which indirectly affect intake and needs. Organizing the documentation following the structure presented in this Minimum Data Set will contribute to a standardized terminology, which may lead to increased quality of documentation, increased continuity of care and improved health outcomes.