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Clinical informatics, decision support for health professionals, electronic health records, and ehealth infrastructures.
JMIR Medical Informatics (JMI, ISSN 2291-9694) is a top-rated, tier A journal which focuses on clinical informatics, big data in health and health care, decision support for health professionals, electronic health records, ehealth infrastructures and implementation. It has a focus on applied, translational research, with a broad readership including clinicians, CIOs, engineers, industry and health informatics professionals.
Published by JMIR Publications, publisher of the Journal of Medical Internet Research (JMIR), the leading eHealth/mHealth journal (Impact Factor 2016: 5.175), JMIR Med Inform has a slightly different scope (emphasizing more on applications for clinicians and health professionals rather than consumers/citizens, which is the focus of JMIR), publishes even faster, and also allows papers which are more technical or more formative than what would be published in the Journal of Medical Internet Research.
JMIR Medical Informatics journal features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs (ready for deposit in PubMed Central/PubMed). The site is optimized for mobile and iPad use.
JMIR Medical Informatics adheres to the same quality standards as JMIR and all articles published here are also cross-listed in the Table of Contents of JMIR, the worlds' leading medical journal in health sciences / health services research and health informatics (http://www.jmir.org/issue/current).
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Background: The adoption and use of an Electronic Health Record can facilitate real-time access to key health information and support improved outcomes. Many Canadian provinces use interoperable Elect...
Background: The adoption and use of an Electronic Health Record can facilitate real-time access to key health information and support improved outcomes. Many Canadian provinces use interoperable Electronic Health Records (iEHRs) to facilitate Health Information Exchange (HIE), but, to date, the clinical use and utility of iEHRs has not been well-described. Objective: Our study's primary objective was to describe the use and reported utility of a provincial iEHR known as the Alberta Netcare Portal (ANP) in four urban Alberta emergency departments (EDs). The secondary objectives were to characterize the time spent using the respective electronic tools, and which aspects were perceived as most useful by ED physicians. Methods: Four EDs were included in the study, two using paper-based ordering (University of Alberta Hospital [UAH] and Grey Nuns Community Hospital [GNCH]) and two using a commercial vendor Clinical Information System (Peter Lougheed Centre [PLC] and Foothills Medical Centre [FMC]). Structured clinical observations of ANP use, semi-structured interviews, and system audit logs analysis were compared at the four sites from October 2014 to March 2016. Results: Observers followed 142 physicians for a total of 566 hours over 376 occasions. The median percentage of observed time spent using ANP was 8.5% at UAH (interquartile range IQR: 3.7% - 13.3%), 4.4% at GNCH (2.4%-4.4%), 4.6% at FMC (2.4%-7.6%), and 5.1% at PLC (3.0%-7.7%). By combining administrative and access audit data, the median number of ANP screens (i.e., results and reports displayed on a screen) accessed per patient visit were 20 at UAH (IQR: 6-67), 9 at GNCH (4-29), 7 at FMC (2-18) and 5 at PLC (2-14) indicating that clinicians found significant value in using ANP while providing ED care. To explore this hypothesis, semi-structured interviews were analyzed using an inductive approach. The themes that emerged from the interviews were that the ANP improved the quality and continuity of care and patient safety. Further enhancements related to medication management would support better outcomes for patients. Conclusions: This study shows that the iEHR is well utilized at the four sites studied and physicians participating in the study perceived ANP had a positive impact on knowledge of their patients, patient safety, and quality and continuity of care. Physicians described high utility and usability of ANP. More study about the clinical impacts of using iEHRs in the Canadian context, including longer term impacts on quality of practice and safety are required.
Background: Participant recruitment, especially for frail elderly hospitalized patients, remains one of the greatest challenges for many research groups. Traditional recruitment methods such as chart...
Background: Participant recruitment, especially for frail elderly hospitalized patients, remains one of the greatest challenges for many research groups. Traditional recruitment methods such as chart reviews or word of mouth notifications for patients in the inpatient setting are often inefficient, low-yielding, time consuming and expensive. Silent Best Practice Alert (BPA) systems have previously been used to improve clinical care but not in clinical research. Objective: This pilot project examined a new EPIC BPA system developed to identify potentially eligible participants in real time to help research teams maximize recruitment accuracy and efficiency of resources. We hypothesized that this tool would reduce the daily screening time, the number of missed potential participants as well as the overall cost needed to recruit the targeted number of patients. Methods: The BPA system was jointly developed by a clinical research and electronic medical records implementation/management team at Partners Healthcare. The was developed and pilot tested in an observational clinical trial to enroll patients admitted for acute exacerbation of chronic pulmonary disease (COPD). We compared the BPA system with our usual method of patient identification (chart reviews and word of mouth referrals) and evaluated for daily screening time, number of missed potential participants as well as the overall cost needed to recruit the targeted number of patients. Results: 559 potentially eligible patients were identified through the two screening methods compared. Of those, 460 patients were identified by both methods, with 99 found by just the Epic Workbench Method and 42 identified by just the silent BPA method. Of the 99 identified by the Epic Workbench, only 12 (12.12%) were considered eligible. Of the 42 identified by the silent BPA method, 30 (71.43%) were considered eligible. A total of 319 “Eligible” patients were identified, and of those 60 participants enrolled in the Emerald-COPD Study. Since implementation, the silent BPA system has found an equivalent of 3 additional patients per week. From the comparison, the silent BPA screening method was shown to be approximately 4 times (23.58%) faster than our previous screening method, projected to save 442.5 hours over the duration of the study. Conclusions: Automation of the recruitment process has allowed us to identify potential participants in real time and avoid missing patients. Silent BPA screening is a considerably faster method which allows for more efficient use of resources. This innovative and instrumental functionality can be specified to the needs of other research studies hoping to utilize the electronic medical records system for participant recruitment.
Ontology is a key enabling technology for the Semantic Web. Web Ontology Language (OWL) is the semantic markup language for publishing and sharing data via ontologies on the Web. OntoKBCF is an ontolo...
Ontology is a key enabling technology for the Semantic Web. Web Ontology Language (OWL) is the semantic markup language for publishing and sharing data via ontologies on the Web. OntoKBCF is an ontology-based knowledge base prototype built in OWL to supply customizable molecular genetics information and health information about cystic fibrosis via EHR interfaces. This paper introduces the construction principles, approaches, design considerations, and representation challenges we faced in the construction of OntoKBCF. More specifically, we examine: (1) what is included in OntoKBCF; (2) how we organized and represented complicated knowledge facts by utilizing basic atomic concepts in a formal and machine-processable manner; (3) how the knowledge facts (i.e., known facts with straightforward or complicated statements) can be made automatically usable via an electronic health record system prototype; and 4) why we constructed OntoKBCF in this way. The main challenges include representing: (1) patient groups comprehensively; (2) uncertain knowledge, ambiguous concepts, and negative statements; and (3) more complicated and detailed molecular mechanisms or pathway information about cystic fibrosis. Although cystic fibrosis is utilized as an example, OntoKBCF should be able to be expanded in a straightforward manner based on its current structure. The construction principles can be referenced for building other human monogenetic diseases knowledge bases.
Background: Use of computed tomography pulmonary angiography (CTPA) in the assessment for pulmonary embolism (PE) has significantly increased over the past two decades. While this technology has impro...
Background: Use of computed tomography pulmonary angiography (CTPA) in the assessment for pulmonary embolism (PE) has significantly increased over the past two decades. While this technology has improved the accuracy of radiologic testing for PE, CTPA also carries the risk of significant iatrogenic harm. Each CTPA carries a 14% risk of contrast induced nephropathy and a lifetime malignancy risk that can be as high as 2.76%. Appropriate use of CTPA can be estimated by monitoring CTPA yield, the percentage of tests positive for PE. This is the first study to propose and validate a computerized method for measuring CTPA yield in the ED. Objective: To assess the validity of a novel computerized method of calculating CTPA yield in the ED. Methods: The electronic health record (EHR) databases at two tertiary care academic hospitals were queried for CTPA orders completed in the ED over one month periods. These visits were linked with an inpatient admission with a discharge diagnosis of PE based on International Classification of Diseases (ICD) codes. The computerized CTPA yield was calculated as the number of CTPA orders with an associated inpatient discharge diagnosis of PE divided by the total number of orders for completed CTPA. This computerized method was then validated by two independent reviewers performing a manual chart review, which included reading the free text radiology reports for each CTPA. Results: A total of 349 CTPA orders were completed during the one month periods at the two institutions. Acute PE was diagnosed on CTPA in 28 of these studies, with a CTPA yield of 7.7%. The computerized method correctly identified 27 of 28 scans positive for PE. The one discordant scan was tied to a patient who was discharged directly from the ED and as a result never received an inpatient discharge diagnosis. Conclusions: This is the first successful validation study of a computerized method for calculating CTPA yield in the ED. This method for data extraction allows for an accurate determination of CTPA yield and is more efficient than manual chart review. With this ability, healthcare systems can monitor for appropriate use of CTPA and the effect of interventions to reduce overuse and decrease preventable iatrogenic harm.
Background: A goal of effective EMR provider documentation platforms is to provide an efficient, concise and comprehensive notation system that will effectively reflect the clinical course, including...
Background: A goal of effective EMR provider documentation platforms is to provide an efficient, concise and comprehensive notation system that will effectively reflect the clinical course, including the diagnoses, treatments and interventions. Objective: Fully redesign and standardize the provider documentation process, seeking improvement in documentation based upon ongoing APR-DRG-based coding records, while maintaining non-inferiority comparing provider satisfaction to our existing documentation process. We estimated the fiscal impact of improved documentation based upon changes in expected hospital payments. Methods: Employing a multidisciplinary collaborative approach, we created an integrated clinical platform that captures data entry from the obstetrical suite, delivery room, NICU nursing and respiratory therapy staff. It provides the sole source for hospital provider documentation in the form of a history and physical exam, daily progress notes, and discharge summary. Health maintenance information, follow-up appointments and running contemporaneous updated hospital course information have selected shared entry and common viewing by the NICU team. Interventions: (1) Improve provider awareness of appropriate documentation through a provider education hand-out and follow-up group discussion. (2) Fully redesign and standardize the provider documentation process building from the native Epic-based software. Measures: (1) Hospital coding department review of all NICU admissions and 3M APR-DRG based calculations of Severity of illness (SOI), risk of mortality (ROM) and case mix index (CMI) scores. (2) Balancing measure: Provider time utilization case study and survey; (3) Average expected hospital payment based upon acuity-based clinical logic algorithm and Payor mix. Results: We compared Pre-intervention (October 2015-October 2016) to Post-intervention (November 2016-May 2017) time-periods and demonstrated: (1) Significant improvement in APR-DRG derived SOI, ROM, CMI: Monthly average SOI scores increased by 11.1% (p = 0.008); Monthly average ROM scores increased by 13.5% ((p = 0.007); Monthly average CMI scores increased by 7.7% (p=0.009). (2) Time study showed increased time to complete H&P and progress notes and decreased time to complete discharge summary: H&P: time allocation increased by 47% (p = 0.053); Progress Note time allocation significantly increased by 91% (p < 0.001); Discharge summary time allocation significantly decreased by 41% (p = 0.032). (3) Survey of all providers: Overall there was positive provider perception of the new documentation process based upon a survey of the provider group. (4) Significantly increased hospital average expected payments: Comparing the PRE- and POST-intervention study periods, there was a $14,020/ month/ patient increase in Average Expected Payment for hospital charges (p < 0.001). There was no difference in payer mix during this time-period. Conclusions: A problem-based NICU documentation EMR more effectively improves documentation, without dissatisfaction by the participating providers, and improves hospital estimations of APR-DRG-based revenue.