Journal of the American Medical Informatics Association : JAMIA
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J Am Med Inform Assoc · Mar 2011
Data from clinical notes: a perspective on the tension between structure and flexible documentation.
Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. ⋯ Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.
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J Am Med Inform Assoc · Jan 2011
Agreement between common goals discussed and documented in the ICU.
Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR. ⋯ The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.
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J Am Med Inform Assoc · Nov 2010
Application of information technology within a field hospital deployment following the January 2010 Haiti earthquake disaster.
Following the January 2010 earthquake in Haiti, the Israel Defense Force Medical Corps dispatched a field hospital unit. A specially tailored information technology solution was deployed within the hospital. The solution included a hospital administration system as well as a complete electronic medical record. ⋯ The establishment of electronic medical records promoted the adequacy of medical treatment and facilitated continuity of care. This experience in Haiti supports the feasibility of deploying information technologies within a field hospital operation. Disaster response teams and agencies are encouraged to consider the use of information technology as part of their contingency plans.
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In 2005, the American Medical Informatics Association undertook a set of activities relating to clinical decision support (CDS), with support from the office of the national coordinator and the Agency for Healthcare Research and Quality. They culminated in the release of the roadmap for national action on CDS in 2006. ⋯ Healthcare quality organizations are increasingly recognizing the role of health information technology in improving care, multi-site CDS demonstration projects are under way, and there are growing incentives for adoption. Specific recommendations include: (1) designating a national entity to coordinate CDS work and collaboration; (2) developing approaches to monitor and track CDS adoption and use; (3) defining and funding a CDS research agenda; and (4) updating the CDS 'critical path'.
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J Am Med Inform Assoc · Jul 2010
Randomized Controlled TrialThe design and evaluation of a graphical display for laboratory data.
Advances in healthcare information technology have provided opportunities to present data in new, more effective ways. In this study, we designed a laboratory display that features small, data-dense graphics called sparklines, which have recently been promoted as effective representations of medical data but have not been well studied. The effect of this novel display on physicians' interpretation of data was investigated. ⋯ Data presentation format can affect how physicians interpret laboratory data. Graphic displays have several advantages over numeric displays but are not always optimal. User, task and data characteristics should be considered when designing information displays.