Health Information Management Journal最新文献

{"title":"Completeness of cancer registry data in a small Iranian province: A capture–recapture approach","authors":"M. Fararouei, M. Marzban, G. Shahraki","doi":"10.1177/1833358316668605","DOIUrl":"https://doi.org/10.1177/1833358316668605","url":null,"abstract":"Background and Objective: The incidence of cancer is rising in Iran, and hence it is important to assess the accuracy of the Iranian cancer registry dataset. In this study, the completeness of the cancer registry in the Kohgiluyeh and Boyer-Ahmad (K&B) province is evaluated. Method: The data of registered cases of cancer of people who were living in the K&B province at the time of diagnosis were obtained from the provincial cancer registry offices in K&B, Fars and all other neighbouring provinces. A capture–recapture method along with log-linear statistical modelling were used for analysis. Results: The results indicated that of 2029 known cases of cancer, only 1400 (31%) were registered by the K&B cancer registry office. Age-adjusted incidence rates for all common types of cancer rose from 307.0 per 100,000 (95% confidence interval (CI); 293.8, 320.3, based on observed cases) to 376.4 per 100,000 (95% CI; 361.7, 391.1, based on expected number of cases estimated by capture–recapture analysis) (p < 0.01). The completeness of cancer registry data varied significantly for different types of cancer. Conclusion: Results suggest that the provincial cancer dataset, which is a part of the national cancer registry programme, is neither complete nor representative. A major improvement in case finding, registry procedures and effective data sharing by provincial cancer registry offices is needed in order to provide valid data for epidemiology of cancer in Iran.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"46 1","pages":"100 - 96"},"PeriodicalIF":3.2,"publicationDate":"2017-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1833358316668605","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49608720","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Best practice in the management of clinical coding services: Insights from a project in the Republic of Ireland, Part 1","authors":"B. Reid, Lee Ridoutt, P. O’Connor, D. Murphy","doi":"10.1177/1833358316687576","DOIUrl":"https://doi.org/10.1177/1833358316687576","url":null,"abstract":"Introduction: This article presents some of the results of a year-long project in the Republic of Ireland to review the quality of the hospital inpatient enquiry data for its use in activity-based funding (ABF). This is the first of two papers regarding best practice in the management of clinical coding services. Methods: Four methods were used to address this aspect of the project, namely a literature review, a workshop, an assessment of the coding services in 12 Irish hospitals by structured interviews of the clinical coding managers, and a medical record audit of the clinical codes in 10 hospitals. Results: The results included here are those relating to the quality of the medical records, coding work allocation and supervision processes, data quality control measures, communication with clinicians, and the visibility of clinical coders, their managers, and the coding service. Conclusion: The project found instances of best practice in the study hospitals but also found several areas needing improvement. These included improving the structure and content of the medical record, clinician engagement with the clinical coding teams and the ABF process, and the use of data quality control measures.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"46 1","pages":"69 - 77"},"PeriodicalIF":3.2,"publicationDate":"2017-01-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1833358316687576","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48826020","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A structured review of chronic care model components supporting transition between healthcare service delivery types for older people with multiple chronic diseases","authors":"M. Sendall, L. Mccosker, K. Crossley, A. Bonner","doi":"10.1177/1833358316681687","DOIUrl":"https://doi.org/10.1177/1833358316681687","url":null,"abstract":"Objective: Older people with chronic diseases often have complex and interacting needs and require treatment and care from a wide range of professionals and services concurrently. This structured review will identify the components of the chronic care model (CCM) required to support healthcare that transitions seamlessly between hospital and ambulatory settings for people over 65 years of age who have two or more chronic diseases. Method: A structured review was conducted by searching six electronic databases combining the terms ‘hospital’, ‘ambulatory’, ‘elderly’, ‘chronic disease’ and ‘integration/seamless’. Four articles meeting the inclusion criteria were included in the review. Study setting, objectives, design, population, intervention, CCM components, outcomes and results were extracted and a process of descriptive synthesis applied. Results and conclusion: All four studies reported only using a few components of the CCM – such as clinical information sharing, community linkages and supported self-management – to create an integrated health system. The implementation of these components in a health service seemed to improve the seamless transition between hospital and ambulatory settings, health outcomes and patient experiences. Further research is required to explore the effect of implementing all CCM components to support transition of care between hospital and ambulatory services.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"46 1","pages":"58 - 68"},"PeriodicalIF":3.2,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1833358316681687","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65608521","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Data Quality Associated with Handwritten Laboratory Test Requests: Classification and Frequency of Data-Entry Errors for Outpatient Serology Tests","authors":"E. Vecellio, M. Maley, G. Toouli, A. Georgiou, J. Westbrook","doi":"10.1177/183335831504400302","DOIUrl":"https://doi.org/10.1177/183335831504400302","url":null,"abstract":"Objective: Manual data-entry of handwritten laboratory test requests into electronic information systems has implications for data accuracy. This study sought to identify the types and number of errors occurring for handwritten serology test requests received from outpatient clinics. Methods: A 15-day audit at a serology laboratory in Sydney, Australia, compared the content of all transcribed serology outpatient test requests in the laboratory information system with the handwritten request form. Results: One or more errors were detected in 67/627 (10.7%) audited requests (N=68 errors). Fifty-one of the errors (75.0%) were transcription errors: the wrong test was transcribed in 40/68 cases (58.8%) – ten of these occurred when the abbreviations ‘HBsAb’ and ‘HBsAg’ were confounded for one another – and transcribed requests were missing a test in 11/68 cases (16.2%). The remaining 17 non-transcription errors (25.0%) described request forms not signed by the ordering clinician, mislabelled specimens, and wrong tests due to computer algorithm errors. Conclusions: Manual data-entry of handwritten serology requests is an error-prone process. Electronic ordering has the potential to eliminate illegible handwriting and transcription errors, thus improving data accuracy in hospital information systems.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"44 1","pages":"12 - 7"},"PeriodicalIF":3.2,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/183335831504400302","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65607808","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Standing Your Ground: The Importance of Health Information Managers Sharing What They Do","authors":"Joan Henderson","doi":"10.1177/183335831504400301","DOIUrl":"https://doi.org/10.1177/183335831504400301","url":null,"abstract":"Health information management professionals have a broad range of skills that are invaluable to the health sector. The advent of the electronic health record has provided the opportunity to aggregate patient data to answer clinical and policy questions in a systematic, timely and reproducible way. The possibility of linking datasets provides greater opportunities for answering clinical and policy questions, and Health Information Managers (HIMs) have the best skill set to inform about data quality, coding and classification, privacy, security, and medicolegal implications involved in the ethical handling of such datasets. HIMs have access to a wealth of data that could improve patient care and reduce unnecessary service utilisation, and that could be used to answer many research questions. Undertaking and publishing research is an excellent avenue for HIMs to promote and strengthen their profession.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"26 1","pages":"4 - 6"},"PeriodicalIF":3.2,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/183335831504400301","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65608144","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lifting the Weight of a Diagnosis-Related Groups Family Change: A Comparison between Refined and Non-Refined DRG Systems for Top-down Cost Accounting and Efficiency Indicators","authors":"A. Zlotnik, Miguel Cuchí Alfaro, María Carmen Pérez Pérez","doi":"10.1177/183335831504400202","DOIUrl":"https://doi.org/10.1177/183335831504400202","url":null,"abstract":"Public healthcare providers in all Spanish Regions – Autonomous Communities (ACs) use All Patients Diagnosis-Related Groups (AP-DRGs) for billing non-insured patients, cost accounting and inpatient efficiency indicators. A national migration to All Patients Refined Diagnosis-Related Groups (APR-DRGs) has been scheduled for 2016. The analysis was performed on 202,912 inpatient care episodes ranging from 2005 to 2010. All episodes were grouped using AP-DRG v25.0 and APR-DRG v24.0. Normalised DRG weight variations for an AP-DRG to APR-DRG migration scenario were calculated and compared. Major differences exist between normalised weights for inpatient episodes depending on the DRGs family used. The usage of the APR-DRG system in Spain without any adjustments, as it was developed in the United States, should be approached with care. In order to avoid reverse incentives and provider financial risks, coding practices should be reviewed and structural differences between DRG families taken into account.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"44 1","pages":"11 - 19"},"PeriodicalIF":3.2,"publicationDate":"2015-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/183335831504400202","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65607790","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Use of Electronic Health Records in Spanish Hospitals","authors":"Guillem Marca, Angelique Perez, M. Blanco-García, E. Miravalles, Pere Soley, B. Ortiga","doi":"10.1177/183335831404300305","DOIUrl":"https://doi.org/10.1177/183335831404300305","url":null,"abstract":"The aims of this study were to describe the level of adoption of electronic health records in Spanish hospitals and to identify potential barriers and facilitators to this process. We used an observational cross-sectional design. The survey was conducted between September and December 2011, using an electronic questionnaire distributed through email. We obtained a 30% response rate from the 214 hospitals contacted, all belonging to the Spanish National Health Service. The level of adoption of electronic health records in Spanish hospitals was found to be high: 39.1% of hospitals surveyed had a comprehensive EHR system while a basic system was functioning in 32.8% of the cases. However, in 2011 one third of the hospitals did not have a basic electronic health record system, although some have since implemented electronic functionalities, particularly those related to clinical documentation and patient administration. Respondents cited the acquisition and implementation costs as the main barriers to implementation. Facilitators for EHR implementation were: the possibility to hire technical support, both during and post implementation; security certification warranty; and objective third-party evaluations of EHR products. In conclusion, the number of hospitals that have electronic health records is in general high, being relatively higher in medium-sized hospitals.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"43 1","pages":"37 - 44"},"PeriodicalIF":3.2,"publicationDate":"2014-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/183335831404300305","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65607260","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Do Electronic Discharge Summaries Contain More Complete Medication Information? A Retrospective Analysis of Paper versus Electronic Discharge Summaries","authors":"E. Lehnbom, M. Raban, S. Walter, K. Richardson, J. Westbrook","doi":"10.1177/183335831404300301","DOIUrl":"https://doi.org/10.1177/183335831404300301","url":null,"abstract":"Complete, accurate and timely hospital discharge summaries are important for continuity of care. The aim of this study was to evaluate the effectiveness of an electronic discharge summary system in improving the medication information provided compared to the information in paper discharge summaries. We conducted a retrospective audit of 199 paper and 200 electronic discharge summaries from a 350-bed teaching hospital in Sydney, Australia. The completeness of medication information, and whether medication changes during the admission were explained, were assessed. Further, the likelihood of any incomplete information having an impact on continuity of care was assessed. There were 1352 and 1771 medication orders assessed in paper and electronic discharge summaries, respectively. Of these, 90.9% and 93.4% were complete in paper and electronic discharge summaries, respectively. The dose (OR 25.24, 95%CI: 3.41–186.9) and route (OR 8.65, 95%CI: 3.46–21.59) fields of medication orders, were more likely to be complete in electronic as compared with paper discharge summaries. There was no difference for drug frequency (OR 1.09, 95%CI: 0.77–1.55). There was no significant improvement in the proportion of incomplete medication orders rated as unclear and likely to impede continuity of care in paper compared with electronic discharge summaries (7.3% vs. 6.5%). Of changes to medication regimen, only medication additions were more likely to be explained in the electronic (n=253, 37.2%) compared to paper (n=104, 14.3%) discharge summaries (OR 3.14; 95%CI: 2.20–4.18). In summary, electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medication information documented. However, explanations of changes to medication regimens remained low, despite this being crucial information. Future efforts should focus on including the rationale for changes to medication regimens in discharge summaries.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"43 1","pages":"12 - 4"},"PeriodicalIF":3.2,"publicationDate":"2014-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/183335831404300301","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65606779","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors Influencing Nurses' Acceptance of Hospital Information Systems in Iran: Application of the Unified Theory of Acceptance and Use of Technology","authors":"R. Sharifian, F. Askarian, Mohtaram Nematolahi, P. Farhadi","doi":"10.1177/183335831404300303","DOIUrl":"https://doi.org/10.1177/183335831404300303","url":null,"abstract":"User acceptance is a precondition for successful implementation of hospital information systems (HISs). Increasing investment in information technology by healthcare organisations internationally has made user acceptance an important issue in technology implementation and management. Despite the increased focus on hospital information systems, there continues to be user resistance. The present study aimed to investigate the factors affecting hospital information systems nurse-user acceptance of HISs, based on the Unified Theory of Acceptance and Use of Technology (UTAUT), in the Shiraz University of Medical Sciences teaching hospitals. A descriptive-analytical research design was employed to study nurses' adoption and use of HISs. Data collection was undertaken using a cross-sectional survey of nurses (n=303). The research model was examined using the LISREL path confirmatory modeling. The results demonstrated that the nurses' behavioural intention (BI) to use hospital information systems was predicted by Performance Expectancy (PE) (β= 2.34, p<0.01), Effort Expectancy (EE) (β= 2.21, p<0.01), Social Influence (SI) (β= 2.63, p<0.01) and Facilitating Conditions (FC) (β= 2.84, p<0.01). The effects of these antecedents of BI explained 72.8% of the variance in nurses' intention to use hospital information systems (R2 = 0.728). Application of the research model suggested that nurses' acceptance of HISs was influenced by performance expectancy, effort expectancy, social influence and facilitating conditions, with performance expectancy having the strongest effect on user intention.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"43 1","pages":"23 - 28"},"PeriodicalIF":3.2,"publicationDate":"2014-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/183335831404300303","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65606790","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Analysis of Questions regarding Morbidity Coding Posted to the Online Coding Clinic of the Korean Medical Record Association","authors":"Y. Boo, Whiejong M. Han, Hyun-Sook Lim, Youngjin Choi","doi":"10.1177/183335831404300304","DOIUrl":"https://doi.org/10.1177/183335831404300304","url":null,"abstract":"Accuracy and consistency in morbidity coding are important in both clinical research and practice. However, Health Information Managers (HIMs) sometimes face difficulties in assigning morbidity codes. To assist them, the Korean Medical Record Association operates an online coding clinic bulletin board, on which HIMs can post questions and receive answers. Frequency analysis and Fisher's exact testing were performed to identify differences among the types of questions posted and the characteristics of the HIMs who posted them. Through statistical analysis, it was found that HIMs working at hospitals with fewer than 500 beds and those with more than 10 years of work experience were found to post more questions than other HIMs. The study also identified the characteristics of HIMs who require more coding education and particular diagnoses for which further training is required. Our findings will assist the development of coding procedures, guidelines, education programs, and a more user-friendly database.","PeriodicalId":55068,"journal":{"name":"Health Information Management Journal","volume":"43 1","pages":"29 - 36"},"PeriodicalIF":3.2,"publicationDate":"2014-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/183335831404300304","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65607079","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}