J Clin Monit Comput - Implementation of a standards-based anaesthesia record compliant with the health level 7 (HL7) clinical document architecture (CDA).

Tópicos

{ ehr(2073) health(1662) electron(1139) }
{ record(1888) medic(1808) patient(1693) }
{ concept(1167) ontolog(924) domain(897) }
{ state(1844) use(1261) util(961) }
{ patient(2315) diseas(1263) diabet(1191) }
{ data(3963) clinic(1234) research(1004) }
{ clinic(1479) use(1117) guidelin(835) }
{ research(1218) medic(880) student(794) }
{ data(3008) multipl(1320) sourc(1022) }
{ system(1976) rule(880) can(841) }
{ learn(2355) train(1041) set(1003) }
{ general(901) number(790) one(736) }
{ risk(3053) factor(974) diseas(938) }
{ spatial(1525) area(1432) region(1030) }
{ patient(2837) hospit(1953) medic(668) }
{ decis(3086) make(1611) patient(1517) }
{ imag(1947) propos(1133) code(1026) }
{ inform(2794) health(2639) internet(1427) }
{ bind(1733) structur(1185) ligand(1036) }
{ sequenc(1873) structur(1644) protein(1328) }
{ framework(1458) process(801) describ(734) }
{ chang(1828) time(1643) increas(1301) }
{ data(1714) softwar(1251) tool(1186) }
{ featur(1941) imag(1645) propos(1176) }
{ perform(999) metric(946) measur(919) }
{ research(1085) discuss(1038) issu(1018) }
{ system(1050) medic(1026) inform(1018) }
{ compound(1573) activ(1297) structur(1058) }
{ health(3367) inform(1360) care(1135) }
{ model(3480) simul(1196) paramet(876) }
{ monitor(1329) mobil(1314) devic(1160) }
{ signal(2180) analysi(812) frequenc(800) }
{ cost(1906) reduc(1198) effect(832) }
{ can(981) present(881) function(850) }
{ implement(1333) system(1263) develop(1122) }
{ model(3404) distribut(989) bayesian(671) }
{ can(774) often(719) complex(702) }
{ data(1737) use(1416) pattern(1282) }
{ measur(2081) correl(1212) valu(896) }
{ imag(1057) registr(996) error(939) }
{ method(1219) similar(1157) match(930) }
{ featur(3375) classif(2383) classifi(1994) }
{ imag(2830) propos(1344) filter(1198) }
{ network(2748) neural(1063) input(814) }
{ imag(2675) segment(2577) method(1081) }
{ take(945) account(800) differ(722) }
{ studi(2440) review(1878) systemat(933) }
{ motion(1329) object(1292) video(1091) }
{ assess(1506) score(1403) qualiti(1306) }
{ treatment(1704) effect(941) patient(846) }
{ surgeri(1148) surgic(1085) robot(1054) }
{ problem(2511) optim(1539) algorithm(950) }
{ error(1145) method(1030) estim(1020) }
{ algorithm(1844) comput(1787) effici(935) }
{ extract(1171) text(1153) clinic(932) }
{ method(1557) propos(1049) approach(1037) }
{ design(1359) user(1324) use(1319) }
{ control(1307) perform(991) simul(935) }
{ model(2220) cell(1177) simul(1124) }
{ care(1570) inform(1187) nurs(1089) }
{ method(984) reconstruct(947) comput(926) }
{ search(2224) databas(1162) retriev(909) }
{ case(1353) use(1143) diagnosi(1136) }
{ howev(809) still(633) remain(590) }
{ studi(1410) differ(1259) use(1210) }
{ import(1318) role(1303) understand(862) }
{ model(2341) predict(2261) use(1141) }
{ visual(1396) interact(850) tool(830) }
{ perform(1367) use(1326) method(1137) }
{ studi(1119) effect(1106) posit(819) }
{ blood(1257) pressur(1144) flow(957) }
{ model(2656) set(1616) predict(1553) }
{ data(2317) use(1299) case(1017) }
{ age(1611) year(1155) adult(843) }
{ medic(1828) order(1363) alert(1069) }
{ group(2977) signific(1463) compar(1072) }
{ sampl(1606) size(1419) use(1276) }
{ gene(2352) biolog(1181) express(1162) }
{ first(2504) two(1366) second(1323) }
{ intervent(3218) particip(2042) group(1664) }
{ activ(1138) subject(705) human(624) }
{ time(1939) patient(1703) rate(768) }
{ patient(1821) servic(1111) care(1106) }
{ use(2086) technolog(871) perceiv(783) }
{ analysi(2126) use(1163) compon(1037) }
{ health(1844) social(1437) communiti(874) }
{ structur(1116) can(940) graph(676) }
{ high(1669) rate(1365) level(1280) }
{ cancer(2502) breast(956) screen(824) }
{ use(976) code(926) identifi(902) }
{ use(1733) differ(960) four(931) }
{ drug(1928) target(777) effect(648) }
{ result(1111) use(1088) new(759) }
{ survey(1388) particip(1329) question(1065) }
{ estim(2440) model(1874) function(577) }
{ process(1125) use(805) approach(778) }
{ activ(1452) weight(1219) physic(1104) }
{ method(1969) cluster(1462) data(1082) }
{ method(2212) result(1239) propos(1039) }
{ detect(2391) sensit(1101) algorithm(908) }

Resumo

With the increasing use of anaesthesia information management systems (AIMS) there is the opportunity for different institutions to aggregate and share information both nationally and internationally. Potential uses of such aggregated data include outcomes research, benchmarking and improvement in clinical practice and patient safety. However, these goals can only be achieved if data contained in records from different sources are truly comparable and there is semantic inter-operability. This paper describes the development of a standard terminology for anaesthesia and also a Domain Analysis Model and implementation guide to facilitate a standard representation of AIMS records as extensible markup language documents that are compliant with the Health Level 7 Version 3 clinical document architecture. A representation of vital signs that is compliant with the International Standards Organization 11073 standard is also discussed.

Resumo Limpo

increas use anaesthesia inform manag system aim opportun differ institut aggreg share inform nation intern potenti use aggreg data includ outcom research benchmark improv clinic practic patient safeti howev goal can achiev data contain record differ sourc truli compar semant interoper paper describ develop standard terminolog anaesthesia also domain analysi model implement guid facilit standard represent aim record extens markup languag document compliant health level version clinic document architectur represent vital sign compliant intern standard organ standard also discuss

Resumos Similares

Appl Clin Inform - Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes. ( 0,676948691546943 )
Methods Inf Med - Snomed CT implementation. Mapping guidelines facilitating reuse of data. ( 0,667183232853271 )
J Am Med Inform Assoc - PEDSnet: a National Pediatric Learning Health System. ( 0,650966260878946 )
J Med Syst - A novel system architecture for the national integration of electronic health records: a semi-centralized approach. ( 0,648942677483835 )
Int J Med Inform - How physicians document outpatient visit notes in an electronic health record. ( 0,642597343490271 )
Int J Med Inform - Applying the archetype approach to the database of a biobank information management system. ( 0,628600741486334 )
Artif Intell Med - Creating personalised clinical pathways by semantic interoperability with electronic health records. ( 0,627485766402528 )
J Am Med Inform Assoc - Electronic health records based phenotyping in next-generation clinical trials: a perspective from the NIH Health Care Systems Collaboratory. ( 0,620886146963603 )
J Am Med Inform Assoc - How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use. ( 0,618755371163687 )
J Med Syst - Quality and cost improvement of healthcare via complementary measurement and diagnosis of patient general health outcome using electronic health record data: research rationale and design. ( 0,617964735070268 )
BMC Med Inform Decis Mak - Developing an electronic health record (EHR) for methadone treatment recording and decision support. ( 0,606953211145238 )
Health Informatics J - Evaluation of ISO EN 13606 as a result of its implementation in XML. ( 0,606400437110767 )
J. Med. Internet Res. - Characteristics of patient portals developed in the context of health information exchanges: early policy effects of incentives in the meaningful use program in the United States. ( 0,605635447408285 )
BMC Med Inform Decis Mak - Beyond the threshold: real-time use of evidence in practice. ( 0,603401449313455 )
J Med Syst - Building clinical data groups for electronic medical record in China. ( 0,60052072533192 )
J Am Med Inform Assoc - Agreement between common goals discussed and documented in the ICU. ( 0,599377351074654 )
AMIA Annu Symp Proc - Electronic laboratory data quality and the value of a health information exchange to support public health reporting processes. ( 0,599350278114383 )
J Biomed Inform - Utilizing RxNorm to support practical computing applications: capturing medication history in live electronic health records. ( 0,598271338845034 )
J Med Syst - Evaluation of the medical records system in an upcoming teaching hospital-a project for improvisation. ( 0,595224096837883 )
J Am Med Inform Assoc - Using the CER Hub to ensure data quality in a multi-institution smoking cessation study. ( 0,593877995144602 )
Telemed J E Health - Teledentistry in practice: literature review. ( 0,593171401850732 )
Perspect Health Inf Manag - Integrating research data capture into the electronic health record workflow: real-world experience to advance innovation. ( 0,591193342464154 )
Perspect Health Inf Manag - Workflow and electronic health records in small medical practices. ( 0,590145301038811 )
J Am Med Inform Assoc - Defining a comprehensive verotype using electronic health records for personalized medicine. ( 0,590050782173771 )
Inform Health Soc Care - Multicentre clinical trials' data management: a hybrid solution to exploit the strengths of electronic data capture and electronic health records systems. ( 0,588490323164021 )
J Med Syst - Performance assessment of EMR systems based on post-relational database. ( 0,587312712726009 )
J Med Syst - An adaptive semantic based mediation system for data interoperability among Health Information Systems. ( 0,586385593587876 )
AMIA Annu Symp Proc - qDIET: toward an automated, self-sustaining knowledge base to facilitate linking point-of-sale grocery items to nutritional content. ( 0,585177618847027 )
J Biomed Inform - Implementing standards for the interoperability among healthcare providers in the public regionalized Healthcare Information System of the Lombardy Region. ( 0,5842083857629 )
J Am Med Inform Assoc - Phased implementation of electronic health records through an office of clinical transformation. ( 0,582471955632209 )
Int J Med Inform - Socio-technical considerations in epilepsy electronic patient record implementation. ( 0,582216200601495 )
BMC Med Inform Decis Mak - Development and evaluation of a de-identification procedure for a case register sourced from mental health electronic records. ( 0,581515530568464 )
Int J Med Inform - Collaboration in electronic medical evidence development: a case study of the Social Security Administration's MEGAHIT System. ( 0,580952461931641 )
J Med Syst - Development of fundamental infrastructure for nationwide EHR in Japan. ( 0,579424582791959 )
Methods Inf Med - Subword-based semantic retrieval of clinical and bibliographic documents. ( 0,578469148716332 )
AMIA Annu Symp Proc - The promise of the CCD: challenges and opportunity for quality improvement and population health. ( 0,576577822634567 )
Appl Clin Inform - Medical student appraisal: electronic resources for inpatient pre-rounding. ( 0,575519500495255 )
AMIA Annu Symp Proc - The Knowledge Program: an innovative, comprehensive electronic data capture system and warehouse. ( 0,574520923249556 )
BMC Med Inform Decis Mak - Impact of a computerized system for evidence-based diabetes care on completeness of records: a before-after study. ( 0,573376761503312 )
J Am Med Inform Assoc - There is no neutral position on fraud! ( 0,572950565107132 )
J Am Med Inform Assoc - The wave has finally broken: now what? ( 0,572474303560353 )
Appl Clin Inform - Diabetes and hypertension quality measurement in four safety-net sites: lessons learned after implementation of the same commercial electronic health record. ( 0,572291630378373 )
AMIA Annu Symp Proc - A Template for Authoring and Adapting Genomic Medicine Content in the eMERGE Infobutton Project. ( 0,572029389477289 )
J Am Med Inform Assoc - Completeness, accuracy, and computability of National Quality Forum-specified eMeasures. ( 0,570501472564806 )
AMIA Annu Symp Proc - Extending the HL7/LOINC Document Ontology Settings of Care. ( 0,569576139918409 )
BMC Med Inform Decis Mak - Retrospective checking of compliance with practice guidelines for acute stroke care: a novel experiment using openEHR's Guideline Definition Language. ( 0,569261568315455 )
J Am Med Inform Assoc - Method of electronic health record documentation and quality of primary care. ( 0,567309601203899 )
AMIA Annu Symp Proc - Developing a formal representation for medication appropriateness criteria. ( 0,566179771625993 )
Int J Med Inform - The trends in EMR and CPOE adoption in Japan under the national strategy. ( 0,565051071562195 )
AMIA Annu Symp Proc - Development of automated quality reporting: aligning local efforts with national standards. ( 0,564946311300576 )
Int J Med Inform - Towards an ontology for data quality in integrated chronic disease management: a realist review of the literature. ( 0,56429599430679 )
AMIA Annu Symp Proc - Methods to identify standard data elements in clinical and public health forms. ( 0,563952049350004 )
Methods Inf Med - An electronic specimen collection protocol schema (eSCPS). Document architecture for specimen management and the exchange of specimen collection protocols between biobanking information systems. ( 0,563276707802534 )
J Am Med Inform Assoc - Improving the quality of cancer care in America through health information technology. ( 0,562197466385589 )
Appl Clin Inform - An analysis of free-text alcohol use documentation in the electronic health record: early findings and implications. ( 0,561932538626321 )
J Med Syst - Factors related to health information exchange participation and use. ( 0,559193431623171 )
Perspect Health Inf Manag - Lessons learned from implementation of voice recognition for documentation in the military electronic health record system. ( 0,558176842603908 )
Int J Med Inform - Analysis and evaluation of the Electronic Health Record standard in China: a comparison with the American national standard ASTM E 1384. ( 0,557948232950606 )
Perspect Health Inf Manag - Registry-based diabetes risk detection schema for the systematic identification of patients at risk for diabetes in West Virginia primary care centers. ( 0,55663673881955 )
AMIA Annu Symp Proc - Leveraging standards to support patient-centric interdisciplinary plans of care. ( 0,556573573191025 )
AMIA Annu Symp Proc - An application for monitoring order set usage in a commercial electronic health record. ( 0,556284929624964 )
Healthc (Amst) - Meaningful use: Floor or ceiling? ( 0,554545531843839 )
AMIA Annu Symp Proc - Piloting a deceased subject integrated data repository and protecting privacy of relatives. ( 0,553528512052653 )
BMC Med Inform Decis Mak - Use of a health information exchange system in the emergency care of children. ( 0,55320021242531 )
J Biomed Inform - Building a robust, scalable and standards-driven infrastructure for secondary use of EHR data: the SHARPn project. ( 0,552880654755072 )
AMIA Annu Symp Proc - Combining infobuttons and semantic web rules for identifying patterns and delivering highly-personalized education materials. ( 0,552775411516449 )
AMIA Annu Symp Proc - Enabling locally-developed content for access through the infobutton by means of automated concept annotation. ( 0,55240798231546 )
J Am Med Inform Assoc - Exchanging care records using HL7 V3 care provision messages. ( 0,552167154444571 )
J Am Med Inform Assoc - The Hub Population Health System: distributed ad hoc queries and alerts. ( 0,551466857801678 )
Healthc (Amst) - Instant replay. ( 0,549951225872609 )
Appl Clin Inform - Capturing information needs of care providers to support knowledge sharing and distributed decision making. ( 0,548695909902183 )
Int J Med Inform - Harmonization of health data at national level: a pilot study in China. ( 0,547592517885371 )
AMIA Annu Symp Proc - Implementing the IT infrastructure for health reform: adoption of health IT among patient-centered medical home practices. ( 0,547363079774401 )
BMC Med Inform Decis Mak - CIS-based registration of quality of life in a single source approach. ( 0,546007286062922 )
Int J Med Inform - Physician experiences transitioning between an older versus newer electronic health record for electronic prescribing. ( 0,545545486979457 )
Appl Clin Inform - Transitioning from a legacy EHR to a commercial, vendor-supplied, EHR: one academic health system's experience. ( 0,54462727943577 )
Comput Methods Programs Biomed - The O3-Vet project: integration of a standard nomenclature of clinical terms in a veterinary electronic medical record for veterinary hospitals. ( 0,544402525053339 )
J Am Med Inform Assoc - The NIAID Division of AIDS enterprise information system: integrated decision support for global clinical research programs. ( 0,542938570248843 )
J Am Med Inform Assoc - Leveraging electronic healthcare record standards and semantic web technologies for the identification of patient cohorts. ( 0,542075205600298 )
J Biomed Inform - Implementations of the HL7 Context-Aware Knowledge Retrieval (Infobutton) Standard: challenges, strengths, limitations, and uptake. ( 0,541247074605308 )
AMIA Annu Symp Proc - Using Anchors to Estimate Clinical State without Labeled Data. ( 0,540621664597679 )
J Am Med Inform Assoc - Are Meaningful Use Stage 2 certified EHRs ready for interoperability? Findings from the SMART C-CDA Collaborative. ( 0,540167478829448 )
AMIA Annu Symp Proc - An integrated billing application to streamline clinician workflow. ( 0,539439812900568 )
J Biomed Inform - Integrating electronic health record information to support integrated care: practical application of ontologies to improve the accuracy of diabetes disease registers. ( 0,539227654357037 )
J Biomed Inform - Clinical data interoperability based on archetype transformation. ( 0,539069361311878 )
J Am Med Inform Assoc - A typology of electronic health record workarounds in small-to-medium size primary care practices. ( 0,538610092556266 )
AMIA Annu Symp Proc - Evaluation of HL7 v2.5.1 electronic case reports transmitted from a healthcare enterprise to public health. ( 0,538216769308114 )
J Biomed Inform - Translating standards into practice: experience and lessons learned at the Department of Veterans Affairs. ( 0,537940940067509 )
AMIA Annu Symp Proc - Comparing content coverage in medical curriculum to trainee-authored clinical notes. ( 0,537857857081165 )
J Am Med Inform Assoc - Harmonized patient-reported data elements in the electronic health record: supporting meaningful use by primary care action on health behaviors and key psychosocial factors. ( 0,53757199054113 )
J Med Syst - Factors associated with health information exchange system usage in a safety-net ambulatory care clinic setting. ( 0,536735836911211 )
BMC Med Inform Decis Mak - Towards plug-and-play integration of archetypes into legacy electronic health record systems: the ArchiMed experience. ( 0,536622446007461 )
J Am Med Inform Assoc - Validity of electronic health record-derived quality measurement for performance monitoring. ( 0,535701566391634 )
Int J Med Inform - Scale-up of networked HIV treatment in Nigeria: creation of an integrated electronic medical records system. ( 0,534549659043381 )
J Med Syst - Mitigating error vulnerability at the transition of care through the use of health IT applications. ( 0,534411859220036 )
BMC Med Inform Decis Mak - The effect of data cleaning on record linkage quality. ( 0,533729776160688 )
J Biomed Inform - A domain analysis model for eIRB systems: addressing the weak link in clinical research informatics. ( 0,533181927029603 )
AMIA Annu Symp Proc - Impacts of EHR Certification and Meaningful Use Implementation on an Integrated Delivery Network. ( 0,533027158932936 )
AMIA Annu Symp Proc - Cross-mapping clinical notes between hospitals: an application of the LOINC Document Ontology. ( 0,532476599249372 )
AMIA Annu Symp Proc - Disease progression subtype discovery from longitudinal EMR data with a majority of missing values and unknown initial time points. ( 0,531857858688466 )