Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation

OBJECTIVES

The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists.

DATA SOURCES

An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists.

STUDY SELECTION

Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models.

DATA EXTRACTION

Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review.

DATA SYNTHESIS

Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records.

CONCLUSIONS

Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.

Structured reporting of prostate magnetic resonance imaging has the potential to improve interdisciplinary communication

BACKGROUND

Effective interdisciplinary communication of imaging findings is vital for patient care, as referring physicians depend on the contained information for the decision-making and subsequent treatment. Traditional radiology reports contain non-structured free text and potentially tangled information in narrative language, which can hamper the information transfer and diminish the clarity of the report. Therefore, this study investigates whether newly developed structured reports (SRs) of prostate magnetic resonance imaging (MRI) can improve interdisciplinary communication, as compared to non-structured reports (NSRs).

METHODS

50 NSRs and 50 SRs describing a single prostatic lesion were presented to four urologists with expert level experience in prostate cancer surgery or targeted MRI TRUS fusion biopsy. They were subsequently asked to plot the tumor location in a 2-dimensional prostate diagram and to answer a questionnaire focusing on information on clinically relevant key features as well as the perceived structure of the report. A validated scoring system that distinguishes between "major" and "minor" mistakes was used to evaluate the accuracy of the plotting of the tumor position in the prostate diagram.

RESULTS

The mean total score for accuracy for SRs was significantly higher than for NSRs (28.46 [range 13.33-30.0] vs. 21.75 [range 0.0-30.0], p < 0.01). The overall rates of major mistakes (54% vs. 10%) and minor mistakes (74% vs. 22%) were significantly higher (p < 0.01) for NSRs than for SRs. The rate of radiologist re-consultations was significantly lower (p < 0.01) for SRs than for NSRs (19% vs. 85%). Furthermore, SRs were rated as significantly superior to NSRs in regard to determining the clinical tumor stage (p < 0.01), the quality of the summary (4.4 vs. 2.5; p < 0.01), and overall satisfaction with the report (4.5 vs. 2.3; p < 0.01), and as more valuable for further clinical decision-making and surgical planning (p < 0.01).

CONCLUSIONS

Structured reporting of prostate MRI has the potential to improve interdisciplinary communication. Through SRs, expert urologists were able to more accurately assess the exact location of single prostate cancer lesions, which can facilitate surgical planning. Furthermore, structured reporting of prostate MRI leads to a higher satisfaction level of the referring physician.

The assessment of interpretation in clinical biochemistry: a personal view

In many laboratories, clinical biochemists add interpretative comments to laboratory reports. There is, however, little evidence base to support this activity. Interpretative comments attached to reports are quite complex, usually consisting of several components that may suggest possible diagnoses and additional tests. Every comment is different, and assessment of interpretation is difficult. We illustrate different approaches which can be used: assessing whole comments or comment components or key phrases; and using independent assessors or a pooled panel of experts. No approach has yet been optimized: assessment is a guide to and not a definition of exact solutions. Although External Quality Assurance Schemes examining interpretation provide information to individual participants on how their comments compare with others, a more important role of these Schemes is to enable us to pool knowledge, and their primary purpose is educational.

Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction

OBJECTIVE

To evaluate associations between the electronic environment, clerical burden, and burnout in US physicians.

PARTICIPANTS AND METHODS

Physicians across all specialties in the United States were surveyed between August and October 2014. Physicians provided information regarding use of electronic health records (EHRs), computerized physician order entry (CPOE), and electronic patient portals. Burnout was measured using validated metrics.

RESULTS

Of 6375 responding physicians in active practice, 5389 (84.5%) reported that they used EHRs. Of 5892 physicians who indicated that CPOE was relevant to their specialty, 4858 (82.5%) reported using CPOE. Physicians who used EHRs and CPOE had lower satisfaction with the amount of time spent on clerical tasks and higher rates of burnout on univariate analysis. On multivariable analysis, physicians who used EHRs (odds ratio [OR]=0.67; 95% CI, 0.57-0.79; P<.001) or CPOE (OR=0.72; 95% CI, 0.62-0.84; P<.001) were less likely to be satisfied with the amount of time spent on clerical tasks after adjusting for age, sex, specialty, practice setting, and hours worked per week. Use of CPOE was also associated with a higher risk of burnout after adjusting for these same factors (OR=1.29; 95% CI, 1.12-1.48; P<.001). Use of EHRs was not associated with burnout in adjusted models controlling for CPOE and other factors.

CONCLUSION

In this large national study, physicians' satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.

[The functioning of emergency medical care in the Russian Federation: analysis of report documentation keeping]

The development of functioning of emergency medical care is one of directions of national health care development. The article presents analysis of indices of functioning of emergency medical care in the Russian Federation: number of stations (departments), medical personnel supply, rate of completed visits of emergency teams, number ofpersons cared during visits, number of hospitalized patients transported by emergency teams (shifts), number of cars of emergency medical care, number of road accidents visited by emergency teams, number of victims of road accidents, immediacy offunctioning. The history ofmaintenance of report documentation of emergency medical care is presented and its complicity of its filling-in is marked.

Creating a Physical Activity Self-Report Form for Youth Using Rasch Methodology

Measurement of youth's physical activity levels is recommended to ensure that children are meeting recommended activity guidelines. This article describes the creation of an instrument to measure youth's levels of physical activity, where a strong test validation perspective (Benson, 1998) was followed to create the scale. The development process involved a mixed-method (qualitative followed by quantitative) framework. First, focus groups were conducted, where results informed item creation. Next, three alternative forms were created with different response formats to measure childrens' frequency of participation in various physical activities and intensity of participation. Lastly, a sample of over 500 middle school children was obtained, where three different response scales were investigated. The optimal scale considered measurement of physical activity using a three-point Likert frequency; intensity of activity participation did not strongly contribute to the measurement of children's activity levels. The final version form is thought to be acceptable for use with children in surveillance and large-group studies, as well as in smaller sample applications.

Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment

Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined (p < 0.0001) and at the off-site locations (p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.

A primer for billing in interventional pain management

The surge of interest in pain from many types of physicians over the past few decades has resulted in a specialty with unique challenges. In response to the growth in pain medicine, pain fellowships have emerged to appropriately diagnose and to treat a wide variety of pain conditions. Despite improvements and standardization among pain fellowships, education in the basics of billing and coding is typically limited. Though courses on proper billing practices exist within the specialty of pain medicine, many new practitioners are challenged by clinical responsibilities with limited training with regards to billing and coding of pain services. Inaccurate billing and coding can result in financial issues and legal ramifications. ICD-10, which is expected later this year, will present additional challenges to effective billing and coding. In summary, there are frequent changes to the rules and regulations governing pain management that can significantly impact practice management. Strong consideration should be made by stakeholders in any pain practitioner to attend regular educational meetings and take steps necessary for continued compliance, efficiency, quality, and profitability. A basic primer on concepts related to billing and code terminology, therefore, is presented for clinicians.

Fall Protection Incentives in the Construction Industry: Literature Review and Field Study

Safety literature confirms that incentives such as money or sunglasses seem to improve safety conditions over the short run. However, no studies could be found which tested the effect of incentives on fall protection for a period longer than a few days. In our research we found that after 6 months, the use of non-material incentives significantly improved on-time delivery and completion rates of a special inspection form (both p <.005). In addition, a questionnaire with embedded critical questions showed that even though workers said that they preferred material incentives, we conclude that their behavior was changed by the treatment (incentives). We further conclude that the use of natural reinforcers seems to influence worker behaviors and perception of management's commitment to safety over the long run, even though workers still say that they prefer tangible rewards. Future work should replicate these findings and explore why workers respond to natural incentives but express a preference for material incentives.

A socio-technical analytical framework on the EHR-organizational innovation interplay: Insights from a public hospital in Greece

The healthcare sector globally is confronted with increasing internal and external pressures that urge for a radical reform of health systems' status quo. The role of technological innovations such as Electronic Health Records (EHR) is recognized as instrumental in this transition process as it is expected to accelerate organizational innovations. This is why the widespread uptake of EHR systems is a top priority in the global healthcare agenda. The successful co-deployment though of EHR systems and organizational innovations within the context of secondary healthcare institutions is a complex and multifaceted issue. Existing research in the field has made little progress thus emphasizing the need for further research contribution that will incorporate a holistic perspective. This paper presents insights about the EHR-organizational innovation interplay from a public hospital in Greece into a socio-technical analytical framework providing a multilevel set of action points for the eHealth roadmap with worldwide relevance.

Acquisition of Character Translation Rules for Supporting SNOMED CT Localizations

Translating huge medical terminologies like SNOMED CT is costly and time consuming. We present a methodology that acquires substring substitution rules for single words, based on the known similarity between medical words and their translations, due to their common Latin / Greek origin. Character translation rules are automatically acquired from pairs of English words and their automated translations to German. Using a training set with single words extracted from SNOMED CT as input we obtained a list of 268 translation rules. The evaluation of these rules improved the translation of 60% of words compared to Google Translate and 55% of translated words that exactly match the right translations. On a subset of words where machine translation had failed, our method improves translation in 56% of cases, with 27% exactly matching the gold standard.

Evaluating a Hierarchical Clinical Event Linkage Model for Clinic-Specific Databases

A relational database model is presented that stores the hierarchical linkages between clinical events with qualifier codes, such that the explicit contextual meaning of an event's attributes is preserved upon retrieval. A retrospective analysis of 302 forms built upon the model showed that 91% of 17,899 data elements requested by clinicians and researchers from 19 clinics were successfully represented, but that 62% were never used more than once. These results reinforce the specificity of clinic-specific databases and the need for unambiguous, explicitly-stored clinical data.

Privacy-preserving Statistical Query and Processing on Distributed OpenEHR Data

Reuse of data from EHRs is essential for many purposes. The objective of the study was to explore how distributed electronic health record (EHR) data can be reused for privacy-preserving statistical query and processing.

METHOD

We have designed and created a proof of concept prototype solution based on the OpenEHR specification to ensure interoperability and to query the EHRs. XMPP was used for communication between the distributed processing components.

RESULTS

We have created a two-phased process where a distributed virtual dataset is first created and thereafter processed using distributed privacy-preserving statistical queries.

CONCLUSION

Health authorities in Norway are currently defining the set of archetypes for the national interoperability program. This will create a common information schema enabling reuse of EHR data for statistical query and processing in a privacy-preserving manner. One benefit of the approach is that information transformation between information models for clinical use and statistical processing can be avoided.

[Structured radiology reports]

The paper reviews the problem of using structured radiology reports. Their salient features are as follows: to work out a protocol in accordance with some pattern, to divide it into subheadings arranged consecutively and logically and broken down by main anatomical structures, types of disease, and study, and to use standardized terminology. The RSNA proposed RadLex system is the most known example of structured reports. The experience in using these protocols has shown that the latter may improve the clearness and informative value of roentgenologists' opinions and alleviate their understanding by physicians of other specialties. However, the systems of writing the structured radiology reports have a number of constraints for the time being, which interfere with their wide clinical introduction. Nonetheless, their use is substantially increasing in the years ahead.

[Radiology report: past, present and future]

The analysis of literature data showed that the creation and implementation of a new form of radiology reports into clinical practice is an actual problem of modern medicine. Although imaging modalities have undergone dramatic evolution over the past century, radiology reporting has remained largely static, in both content and structure. In recent years the necessity to create a structured reporting is widely discussed in the literature. A universal format of radiology report hasn't been found yet. The standard of reporting system is absent, a wide variety of styles in radiology reporting currently exists. The challenging goal is improvement of existing protocols and creation of a new form of radiology reports--the protocols of the future.

Integrating standard operating procedures and industry notebook standards to evaluate students in laboratory courses

To enhance the preparedness of graduates from the Biochemistry and Biotechnology (BCBT) Major at Minnesota State University Moorhead for employment in the bioscience industry we have developed a new Industry certificate program. The BCBT Industry Certificate was developed to address specific skill sets that local, regional, and national industry experts identified as lacking in new B.S. and B.A. biochemistry graduates. The industry certificate addresses concerns related to working in a regulated industry such as Good Laboratory Practices, Good Manufacturing Practices, and working in a Quality System. In this article we specifically describe how we developed a validation course that uses Standard Operating Procedures to describe grading policy and laboratory notebook requirements in an effort to better prepare students to transition into industry careers.

Recognizing Questions and Answers in EMR Templates Using Natural Language Processing

Templated boilerplate structures pose challenges to natural language processing (NLP) tools used for information extraction (IE). Routine error analyses while performing an IE task using Veterans Affairs (VA) medical records identified templates as an important cause of false positives. The baseline NLP pipeline (V3NLP) was adapted to recognize negation, questions and answers (QA) in various template types by adding a negation and slot:value identification annotator. The system was trained using a corpus of 975 documents developed as a reference standard for extracting psychosocial concepts. Iterative processing using the baseline tool and baseline+negation+QA revealed loss of numbers of concepts with a modest increase in true positives in several concept categories. Similar improvement was noted when the adapted V3NLP was used to process a random sample of 318,000 notes. We demonstrate the feasibility of adapting an NLP pipeline to recognize templates.

A case study on parsing chemotherapy related free-text data

When modelling and simulating healthcare related processes, free-text data is often the only possible source of information. This data may contain vocabulary variations such as mistyped, misspelled and/or abbreviated words. This paper describes a semi-automated approach to free-text normalisation based on a combination of commonly used techniques and local expertise of medical oncology nurses. The approach emphasises the effectiveness of the vocabulary creation process through an interactive software application. When local knowledge is successfully captured, normalisation of large data sets can be done very rapidly with a high accuracy rate achieved. Furthermore, the techniques for localised normalisation can have significant benefits to free-text parsing accuracy when data is aggregated from multiple sites (hospitals). This research may lead to increased understanding of issues associated with chemotherapy related free-text data which in turn may impact patient treatment safety.

Remote source document verification in two national clinical trials networks: a pilot study

OBJECTIVE

Barriers to executing large-scale randomized controlled trials include costs, complexity, and regulatory requirements. We hypothesized that source document verification (SDV) via remote electronic monitoring is feasible.

METHODS

Five hospitals from two NIH sponsored networks provided remote electronic access to study monitors. We evaluated pre-visit remote SDV compared to traditional on-site SDV using a randomized convenience sample of all study subjects due for a monitoring visit. The number of data values verified and the time to perform remote and on-site SDV was collected.

RESULTS

Thirty-two study subjects were randomized to either remote SDV (N=16) or traditional on-site SDV (N=16). Technical capabilities, remote access policies and regulatory requirements varied widely across sites. In the adult network, only 14 of 2965 data values (0.47%) could not be located remotely. In the traditional on-site SDV arm, 3 of 2608 data values (0.12%) required coordinator help. In the pediatric network, all 198 data values in the remote SDV arm and all 183 data values in the on-site SDV arm were located. Although not statistically significant there was a consistent trend for more time consumed per data value (minutes +/- SD): Adult 0.50 +/- 0.17 min vs. 0.39 +/- 0.10 min (two-tailed t-test p=0.11); Pediatric 0.99 +/- 1.07 min vs. 0.56 +/- 0.61 min (p=0.37) and time per case report form: Adult: 4.60 +/- 1.42 min vs. 3.60 +/- 0.96 min (p=0.10); Pediatric: 11.64 +/- 7.54 min vs. 6.07 +/- 3.18 min (p=0.10) using remote SDV.

CONCLUSIONS

Because each site had different policies, requirements, and technologies, a common approach to assimilating monitors into the access management system could not be implemented. Despite substantial technology differences, more than 99% of data values were successfully monitored remotely. This pilot study demonstrates the feasibility of remote monitoring and the need to develop consistent access policies for remote study monitoring.

Using tablet technology in operational radiation safety applications

Tablet computers have become a mainstream product in today's personal, educational, and business worlds. These tablets offer computing power, storage, and a wide range of available products to meet nearly every user need. To take advantage of this new computing technology, a system was developed for the Apple iPad (Apple Inc. 1 Infinite Loop Cupertino, CA 95014) to perform health and safety inspections in the field using editable PDFs and saving them to a database while keeping the process easy and paperless.

[Establishment and management of documentation within QMS of medical device enterprises]

The objectives of QMS for quality assurance of products are achieved by formulation, implement, and management of document system. Document (includes record) system is important constituent part of QMS. In this paper, the important issues and relative requirements of GMP on the establishment and management of documentation within quality management system (QMS) of medical device enterprises are discussed with the aim of providing reference for relative enterprises to build and improve their QMS and to implement GMP.

Surgical hospital audit of record keeping (SHARK)--a new audit tool for the improvement in surgical record keeping

INTRODUCTION

Accurate and legible record keeping is a crucial part of good medical practice. Surgical Hospital Audit of Record Keeping (SHARK) is a new audit and teaching tool for junior doctors. The author has designed the tool, based on the Royal College of Surgeons guidelines, to anonymously score the different surgical teams' medical records within a hospital. It takes into account regular record keeping during ward rounds, together with the operation note and admission clerking.

METHODS

The SHARK audit tool assesses 45 individual areas within surgical records. Fifteen points are apportioned for an initial surgical clerking, 13 for a subsequent record entry, and 17 for the operation note to give an overall score out of 45. It was implemented at 2 hospitals and used to educate medical students.

RESULTS

The results were poor and improved with education at both sites. There was 80% total agreement with a κ coefficient for interobserver reliability of 0.6.

CONCLUSION

This study shows that the SHARK tool is simple to use, repeatable, and reliable in improving record keeping.

Treatment outcome monitoring of pulmonary tuberculosis cases notified in France in 2009

The proportion of patients considered to be cured is a key indicator to assess national tuberculosis (TB) control. In France, TB treatment outcome monitoring was implemented in 2007. This article presents national results on treatment outcome among patients with pulmonary TB reported in France in 2009 and explores determinants of potentially unfavourable outcome. Information on treatment outcome was reported for 63% of eligible pulmonary cases of whom 70% had a successful outcome. In a multivariate analysis, potentially unfavourable outcome (17%), compared to treatment success, was significantly associated with being male, born abroad and having lived in France for less than 10 years, being in congregate settings when treatment was initiated, or having a previous history of anti-TB treatment. Enhanced awareness of treatment outcome monitoring is essential to improve the coverage and the quality of information. Earlier diagnosis and improved management of the disease in the elderly may reduce death due to TB. The high proportion of potentially unfavourable outcomes should be further investigated as they may require additional vigilance and/or actions in term of efforts of TB control in some population groups.

Building electronic forms for elderly program: integrated care model for high risk elders in Hong Kong

In Hong Kong, elderly patients discharged from hospital are at high risk of unplanned readmission. The Integrated Care Model (ICM) program is introduced to provide continuous and coordinated care for high risk elders from hospital to community to prevent unplanned readmission. A multidisciplinary working group was set up to address the requirements on developing the electronic forms for ICM program. Six (6) forms were developed. These forms can support ICM service delivery for the high risk elders, clinical documentation, statistical analysis and information sharing.

Analyses of medical data models - identifying common concepts and items in a repository of medical forms

One year ago the portal of Medical Data Models (http://medical-data-models.org) was presented as a resource for the scientific community. As of November 2012 there are approximately 3,300 forms with 102,000 items available in the CDISC ODM format. First descriptive analyses regarding form metadata demonstrate the capability of such a repository to identify commonly used medical concepts. Most common items are administrative attributes which indicates that more clinical information are needed to increase the secondary use of data documented within these forms.

Knowledge representation and management enabling intelligent interoperability - principles and standards

Based on the paradigm changes for health, health services and underlying technologies as well as the need for at best comprehensive and increasingly automated interoperability, the paper addresses the challenge of knowledge representation and management for medical decision support. After introducing related definitions, a system-theoretical, architecture-centric approach to decision support systems (DSSs) and appropriate ways for representing them using systems of ontologies is given. Finally, existing and emerging knowledge representation and management standards are presented. The paper focuses on the knowledge representation and management part of DSSs, excluding the reasoning part from consideration.

Developing a multivariate electronic medical record integration model for primary health care

This paper describes the development of a multivariate electronic medical record (EMR) integration model for the primary health care setting. Our working hypothesis is that an integrated EMR is associated with high quality primary health care. Our assumption is that EMR integration should be viewed as a form of complex intervention with multiple interacting components that can impact the quality of care. Depending on how well the EMR is integrated in the practice setting, one can expect a corresponding change in the quality of care as measured through a set of primary health care quality indicators. To test the face validity of this model, a Delphi study is being planned where health care providers and information technology professionals involved with EMR adoption are polled for their feedback. This model has the potential to quantify and explain the factors that influence successful EMR integration to improve primary health care.

Machine learning methods for clinical forms analysis in mental health

In preparation for a clinical information system implementation, the Centre for Addiction and Mental Health (CAMH) Clinical Information Transformation project completed multiple preparation steps. An automated process was desired to supplement the onerous task of manual analysis of clinical forms. We used natural language processing (NLP) and machine learning (ML) methods for a series of 266 separate clinical forms. For the investigation, documents were represented by feature vectors. We used four ML algorithms for our examination of the forms: cluster analysis, k-nearest neigh-bours (kNN), decision trees and support vector machines (SVM). Parameters for each algorithm were optimized. SVM had the best performance with a precision of 64.6%. Though we did not find any method sufficiently accurate for practical use, to our knowledge this approach to forms has not been used previously in mental health.

[Self-evaluation of health state in athletes]

The article covers scientific basis and elaboration of system concerning self-evaluation of athletes' health state. The study comprised 2 steps. During the first step, a group of 62 athletes (45 males and 17 females) performed methods of self-evaluation of health state through a list of changes, tests and stress testing. The second step included processing and generalization of the data obtained and specification of an integral scale of self-evaluation of athletes health state.

Computer-aided treat to target (T2T) Approach for the Rheumatology Patient

Since 2001,we had been using a document template with manual calculators to assess the disease status during each visit and based on that, formulate a proper treatment plan for our patients We had good outcomes but the process was laborious and slow. From 2007 onwards, we shifted to a rheumatology specific EMR with automatic calculators. This article compares outcomes of Rheum Aid® (a clinician developed EMR for rheumatology) supported "Objectified Assessment" and prescription writing on patients with rheumatic diseases versus previous use of an MS Word® document template and shows better turnover and patient satisfaction.

AccessMRS: integrating OpenMRS with smart forms on Android

We present a new open-source Android application, AccessMRS, for interfacing with an electronic medical record system (OpenMRS) and loading 'Smart Forms' on a mobile device. AccessMRS functions as a patient-centered interface for viewing OpenMRS data; managing patient information in reminders, task lists, and previous encounters; and launching patient-specific 'Smart Forms' for electronic data collection and dissemination of health information. We present AccessMRS in the context of related software applications we developed to serve Community Health Workers, including AccessInfo, AccessAdmin, AccessMaps, and AccessForms. The specific features and design of AccessMRS are detailed in relationship to the requirements that drove development: the workflows of the Kenyan Ministry of Health Community Health Volunteers (CHVs) supported by the AMPATH Primary Health Care Program. Specifically, AccessMRS was designed to improve the quality of community-based Maternal and Child Health services delivered by CHVs in Kosirai Division. AccessMRS is currently in use by more than 80 CHVs in Kenya and undergoing formal assessment of acceptability, effectiveness, and cost.

Coding and Reimbursement for Weight Loss Surgery: Best Practice Recommendations

OBJECTIVE

To review the use and usefulness of billing codes for services related to weight loss surgery (WLS) and to examine third party reimbursement policies for these services.

RESEARCH METHODS AND PROCEDURES

The Task Group carried out a systematic search of MEDLINE, the Internet, and the trade press for publications on WLS, coding, reimbursement, and coding and reimbursement policy. Twenty-eight articles were each reviewed and graded using a system based on established evidence-based models. The Massachusetts Dietetics Association provided reimbursement data for nutrition services. Three suppliers of laparoscopic WLS equipment provided summaries of coding and reimbursement information. WLS program directors were surveyed for information on use of procedure codes related to WLS.

RESULTS

Recommendations focused on correcting or improving on the current lack of congruity among coding practices, reimbursement policies, and accepted clinical practice; lack of uniform coding and reimbursement data across institutions; inconsistent and/or inaccurate diagnostic and billing codes; inconsistent insurance reimbursement criteria; and inability to leverage reimbursement and coding data to track outcomes, identify best practices, and perform accurate risk-benefit analyses.

DISCUSSION

Rapid changes in the prevalence of obesity, our understanding of its clinical impact, and the technologies for surgical treatment have yet to be adequately reflected in coding, coverage, and reimbursement policies. Issues identified as key to effective change include improved characterization of the risks, benefits, and costs of WLS; anticipation and monitoring of technological advances; encouragement of consistent patterns of insurance coverage; and promotion of billing codes for WLS procedures that facilitate accurate tracking of clinical use and outcomes.

Ethical review from the inside: repertoires of evaluation in Research Ethics Committee meetings

Evaluating the practice of ethical review by Research Ethics Committees (REC) could help protect the interests of human participants and promote scientific progress. To facilitate such evaluations, we conducted an ethnographic study of how an REC reviews research proposals during its meetings. We observed 13 meetings of a Dutch REC and studied REC documents. We coded this material inductively and categorised these codes in two repertoires of evaluation: a repertoire of rules and a repertoire of production. In the repertoire of rules the REC applies rules, weighs scientific value and burdens to the participants and makes a final judgment on a research proposal in a meeting. In the repertoire of production, REC members check documents and forms and advise researchers on how to improve their proposals and can use informal communication. Based on these findings, we think that evaluations of the practice of ethical review should take into account the fact that RECs can use a repertoire of rules and a repertoire of production to evaluate research proposals. Combining these two repertoires can be a viable option so that the REC gives researchers advice on how to improve their proposals to prevent rejection of valuable research.

Practice Committees of American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology. Recommendations for development of an emergency plan for in vitro fertilization programs: a committee opinion

All in vitro fertilization (IVF) programs and clinics should have a plan to protect fresh and cryopreserved human tissue (embryos, oocytes, sperm) and to provide for continuation of patient care in the event of an emergency or natural disaster. This document was reviewed and affirmed by the Practice Committee in 2011.

Ontology-based reusable clinical document template production system

Clinical documents embody professional clinical knowledge. This paper shows an effective clinical document template (CDT) production system that uses a clinical description entity (CDE) model, a CDE ontology, and a knowledge management system called STEP that manages ontology-based clinical description entities. The ontology represents CDEs and their inter-relations, and the STEP system stores and manages CDE ontology-based information regarding CDTs. The system also provides Web Services interfaces for search and reasoning over clinical entities. The system was populated with entities and relations extracted from 35 CDTs that were used in admission, discharge, and progress reports, as well as those used in nursing and operation functions. A clinical document template editor is shown that uses STEP.

Recognition and privacy preservation of paper-based health records

While the digitization of medical data within electronic health records has been introduced in some areas, massive amounts of paper-based health records are still produced on a daily basis. This data has to be stored for decades due to legal reasons but is of no benefit for research organizations, as the unstructured medical data in paper-based health records cannot be efficiently used for clinical studies. This paper presents a system for the recognition and privacy preservation of personal data in paper-based health records with the aim to provide clinical studies with medical data gained from existing paper-based health records.

A semantic approach for digital long-term preservation of electronic health documents

Long-term preservation of electronic patient health information is a key issue for life-long electronic health records, however, it is poorly implemented in healthcare institutions and little attention is given to problems like obsolescence of formats and EHR applications or changing regulations, which jeopardize reusability of information after decades of preservation. We present in this paper an ontology driven approach to digital preservation and related metadata management which seems to be superior to conventional concepts of the digital library world.

Use of an evidence-based shift report tool to improve nurses' communication

Using steps in the Iowa Model of Evidence-Based Practice, nursing staff developed and piloted a standardized shift report tool on one medical-surgical unit in a large tertiary care hospital. Pilot outcomes showed shift reports with decreased frequency of missed information, fewer delays in shift starting time, and less use of overtime.

The importance of defining 'data' in data management policies: Commentary on: "Issues in data management"

What comprises 'data' varies from one institution to another based on the information which is deemed important by individual institutions. To effectively and efficiently produce, collect, and retain data, an organization develops specific defining characteristics of data to meet its informational needs. Procedures to maintain and retain knowledge among laboratory members and principal investigators will allow for improved efficiency of data collection. Optimization of communication, maintenance of inventories, record keeping, and updating relevant training programs are all critical to supporting the quality and integrity of a particular organization's data. Concurrent revisions to such procedures will ensure that the definition of data as well as the means by which it is collected and maintained remain appropriate to the needs of the individual organization.

Issues in data management

Data management raises a number of issues, both regulatory and non-regulatory. Researchers should understand how data are defined by their particular institutions and regulatory authorities. Data are the bases of scientific communication and provide a strong defense against allegations of scientific misconduct. Authorization is often necessary before collection of data can commence. Proper handling, retention, and storage of data, especially that involving humans, are crucial for the researcher. Data ownership by the institution leads to a responsibility by the institution to educate all its researchers in responsible data management practices.