Community based estimation of perinatal mortality through record linkage

OBJECTIVE: To estimate perinatal mortality through record linkage of Health Workers (HW) and Anganwadi Workers (AWW) in rural Haryana. DESIGN: Retrospective analysis of records (1991-92) of HW and AWW. Enquiry and home visits were made for tracing the fate of pregnancy in cases with incomplete records. SETTING: In 1993-95 in 45 villages selected purposively in Raipur Rani block, Ambala. MAIN OUTCOME MEASURE: Enlisting of perinatal deaths as the main outcome measure through scrutiny of records of HW and AWW. RESULTS: Perinatal mortality rate (PMR) was 42.25 and 45.78 per thousand births as per the record of HW and AWW, respectively for the 23 villages for whom records of both were available. Support by enquiry or home visit yielded a PMR of 59.42 for combined HW and AWW sources and 51.66 per 1000 births for AWW source alone. Concordance between AWW and HW records for fate of pregnancy was moderate (K = 0.46; 95% CI 0.35-0.57). CONCLUSIONS: There is a lack of a system of record linkage between and within the records of HW and AWW at primary health care level. AWW data was more accurate and up-to-date as compared to HW. Reasonably accurate estimates of perinatal mortality rate can be made through record linkage.     

Undocumented smokeless tobacco use in a family practice population

BACKGROUND: Smokeless tobacco (ST) use is associated with significant health risks and is increasing in prevalence in the United States. This study examined the prevalence of ST use among patients seen in two family practice centers and the documentation of that ST use in the medical record. METHODS: A survey of 209 patients seen in two family practice centers in northeast Tennessee was done to determine current and former smoking and ST use. Charts of all current ST users were reviewed for additional data. RESULTS: Current ST use was reported by 7.7% of patients. Highest rates were found in middle-aged men (27.8%) and elderly women (14.8%). Physicians rarely recorded ST use as a significant problem in the medical record. In several cases, management of other medical conditions may have been compromised by the physicians' lack of awareness of the ST use. CONCLUSIONS: The use of smokeless tobacco may be an important unrecognized problem in patients seen in family physicians' offices.     

The association between child maltreatment and disabilities in a hospital-based epidemiological study

OBJECTIVE: Circumstances of maltreatment and the presence of disabilities. METHOD: An electronic merger of the records of all pediatric patients. RESULTS: Detailed record analysis of circumstances of maltreatment and the presence of disabilities. CONCLUSIONS: Differences between the Hospital and Residential samples, maltreatment and perpetrator characteristics, disability/maltreatment relationships, and their implications for primary health care are discussed.     

Comparison of continuity clinic experience by practice setting and postgraduate level

OBJECTIVE: To compare continuity clinic experiences by practice setting and postgraduate level. DESIGN: Mailed questionnaire. SETTING: Baylor College of Medicine pediatric residents selected 1 of 3 continuity practice settings, including community-based private offices (n = 35) and university-based clinics in a private (n = 71) and a public (n = 12) hospital. SUBJECTS: One hundred eighteen pediatric residents, May 1993. OUTCOME MEASURES: Patient volume, continuity of care, type of patient visit, and faculty supervision. RESULTS: The response rate was 77% (91/118). Pediatric residents in community-based private offices reported seeing more patients per session than those in the university-based private and public clinics (88%, 10%, and 0% residents in the respective practice settings reported > or = 4 patients per session), but were less likely to see patients repeatedly (6%, 68%, and 40% residents in the respective practice settings had seen more than half their patients > 2 times). Residents in private offices provided a smaller percentage of well child care (16%, 61%, and 90% residents in the respective practice settings reported > 50% patients were well) and more acute care (68%, 15% and 0% residents in the respective practice settings reported > 25% patients were acutely ill). Residents in private offices reported a higher percentage of time spent observing only (33%, 0%, and 0% residents in the respective practice settings observed > 25% of the time) and less time managing patients independently (93%, 59%, and 40% residents, respectively, managed < or = 25% of the time). No significant differences among postgraduate levels were found for these variables. CONCLUSIONS: Patient volume, continuity of care, type of patient visit, and faculty supervision were significantly different among continuity practice settings. Postgraduate level of training did not affect significantly these measures of continuity clinic experience. These differences need to be considered in curriculum development.     

The medical record: a comprehensive computer system for the family physician

BACKGROUND: Despite the early excitement regarding the possible uses of computers in medical care in the 1980s, the computer has not had much effect on routine outpatient medicine except for billing and accounting. METHODS: An emerging comprehensive ambulatory care computer system, The Medical Record (TMR), is used extensively in a large family practice, the Duke Family Medicine Center. TMR is the central system for accounting, appointments, billing, and reporting of laboratory results, radiographic findings, and medications. TMR also records problem lists and generates prompts to the clinicians for needed health maintenance, laboratory tests, and reminder letters. The most innovative function of TMR is the computerized obstetric patient record, which can be accessed from multiple sites. Cost savings compared with a manual system were found to be in excess of $7 per patient visit or approximately $500,000 per year for the Duke Family Medicine Center. RESULTS AND CONCLUSIONS: A comprehensive computer system in a large family practice is cost effective and facilitates better patient care through improved access to patient data.     

Resident documentation of diagnostic impression in sexual abuse evaluations

In sexual abuse evaluations, the documentation of the examiner's diagnostic impression is essential. If the diagnostic impression is not documented, the examiner will have to rely on memory rather than the medical record when called to testify. The purpose of this study was to determine whether pediatric residents adequately document their diagnostic impression in child sexual abuse evaluations. We performed a three-year retrospective chart review from patients 0-17 years of age who were evaluated at our emergency room for suspected sexual abuse. We reviewed 1,487 charts for historical information, physical findings, and diagnostic impression. Physical findings were categorized as normal, nonspecific, suggestive, or indicative of penetration. In 77% of cases (N = 256) with hymenal findings indicative of penetration and 84% of cases (N = 31) with vaginal findings indicative of penetration, residents recorded no impression or a nonspecific impression. Results were similar for vulvar and rectal findings indicative of penetration. Residents fail to document an adequate interpretation of their physical examinations in sexual abuse evaluations.     

Adherence to Agency for Health Care Policy and Research guidelines for benign prostatic hyperplasia

PURPOSE: We determined adherence rates to guideline recommendations for the diagnosis and treatment of benign prostatic hyperplasia published and distributed by the Agency for Health Care Policy and Research in 1994. MATERIALS AND METHODS: Measures of care were developed based upon Agency for Health Care Policy and Research guideline recommendations approved by the Health Care Financing Administration and the American Urological Association (AUA). A random 4-state sample of 2,000 inpatient records with a principal diagnosis of hyperplasia of the prostate (ICD-9-CM code 600) and principal procedure code of 60.2 was selected by the Health Care Financing Administration and abstractions were performed. We assessed reliability and validity and determined results for each of the following measures of care: 1) documentation of indications for a transurethral resection of the prostate; 2) documentation of appropriate preoperative assessment; 3) documentation of indications for an inpatient excretory urogram (IVP) and/or sonogram when the procedures were performed and 4) documentation of surgical time and grams of tissue removed. Adherence rates for all measures of care were determined. RESULTS: Of the 4-state sample of inpatient cases 1,828 cases met entry criteria for the study. Of the cases 93% had at least 1 symptom and/or score, and/or an anatomical abnormality documented before surgery. An AUA score was documented in the inpatient medical record in 7.5% of the cases. Recommendations for preoperative evaluation included urinalysis, a digital rectal exam and determination of preoperative creatinine. All of these were documented in 475 (26%) cases. Of the 1,828 cases 216 (12%) had an IVP or sonogram performed in the inpatient setting. In 36% indications were documented when sonograms were performed; 74% had documented indications when IVPs were performed. Excluding laser transurethral resections of the prostate, surgical time and tissue amounts were documented and recorded in 1,424 transurethral resections of the prostate cases (91%). CONCLUSIONS: Adherence to selected Agency for Health Care Policy and Research guideline recommendations is documented infrequently in the medical record.     

Evaluation of the quality of filling out medical records in a hypertension consultation

The aim of the study was to evaluate the completion of medical records of a hypertension clinic and to compare standardized computerized records versus standard medical records. The medical records of 163 consecutive hypertensive patients attending at the Broussais hospital hypertension clinic between December 1995, 6th and January 1996, 21st were checked. At the last visit, the patients were attended by 16 physicians working in 4 different teams. The medical data were recorded by physicians in the computerized system called ARTEMIS in 120 patients and in standard structured forms in 43 patients. The patients notes were checked to see if 9 clinical items were recorded at the first visit (V1), at the visit before last (V2) and at the last visit (V3). The overall completion rate was high at V1 (92.2%) and significantly decreased at follow-up visits (82.6% at V2 and 83.2% at V3). The completion rate was significantly higher in the computerized records than in the standard notes: 95.8% vs 82.2% at V1, 91.9% vs 56.3% at V2 and 91.6% vs 59.7% at V3. During follow-up (V2 vs V1), a significant decrease in the completion rate of 6 items was observed in the standard notes (tobacco use, alcohol consumption, physical activity, compliance to treatment, body weight, manual blood pressure measurement). In the computerized records, only physical activity completion rate decreased. In conclusion, the computer may help to increase the quality of the medical records as reflected by the completion rate of items related to hypertension care.     

Medical Records for Building Health Management

Medical records provide essential information for evaluating a patient’s health. Without them, it would be difficult for doctors to make accurate diagnoses. Similar to diagnoses in medical science, building health management also requires building medical records for making accurate diagnoses. At later stages of a building’s life cycle, when the budget is limited, organizations responsible for building repairs and maintenance are unable to digitalize building health diagnoses and keep complete medical records of buildings; as a result, maintenance crews usually cannot fully understand buildings’ overall health conditions and their medical histories, which may result in erroneous diagnoses directly or public safety dangers indirectly. Using the problem-oriented medical record adopted for the medical diagnosis of human diseases, this paper designs a building medical record (BMR), which allows simple electronic archiving, and evaluates its practicability with a case study of school buildings. The purpose of a BMR is to enable maintenance engineers (building doctors), building managers, and contractors of school buildings to have low-cost access to required information for making complete evaluations and maintenance suggestions for buildings.     

Computer based nursing documentation means to achieve the goal

New functions have been integrated in the Giessen Hospital Information System WING to support the classification of all intensive care patients into the Therapeutic Intervention Scoring System (TISS). The use of those functions has been pushed when health insurance bodies demanded evidence for the correct classification of ICU beds. This article presents an overview on this development from the start in just one intensive care unit to the complete coverage of six intensive care units and three intensive monitoring units with a total of 109 beds. For those units complete TISS data has been documented for more than a year now at a detailed level. On average 14 interventions have been recorded per patient and day, accumulating to a database with more than a million entries. We describe the experiences made during introduction and the different front-end applications we used to achieve the goal. Results gained from the huge database and their implications for our future work are discussed. TISS documentation is now an established routine on every intensive care unit of our University hospital. It has been implemented without major financial or manpower investments and no specific intensive care information system has been needed. Establishing this type of basic care documentation made nurses aware of their activities, so that now they consider electronic care documentation to be in their very own interest. The next goal has been set by nurses themselves, they want to establish intervention based care documentation on normal wards as well. We think that step by step we will thus be able to achieve a more complete electronic patient record.     

Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids

CONTEXT: While clinical guidelines are considered an important mechanism to improve the quality of medical care, problems with implementation may limit their effectiveness. Few empirical data exist about the effect of computer-based systems for application of clinical guidelines on quality of care. OBJECTIVE: To determine whether real-time presentation of clinical guidelines using an electronic medical record can increase compliance with guidelines. DESIGN: Prospective off-on-off, interrupted time series with intent-to-treat analysis. SETTING: University hospital emergency department. SUBJECTS: Patients were 280 health care workers (50 in the baseline control phase, 156 in the intervention phase, and 74 in the postintervention control phase) who presented for initial treatment of occupational body fluid exposures, including 89% (248/280) who sustained punctures and 81% (208/257) who were exposed to blood. Physicians included resident physicians and attending physicians working in the emergency department during the study. INTERVENTIONS: Implementation of a computer charting system that provides real-time information regarding history and recommendations for laboratory testing, treatment, and disposition based on rules derived from clinical guidelines. MAIN OUTCOME MEASURES: Quality of care as determined by essential items documented in the medical record and in aftercare instructions, compliance with testing and treatment guidelines, and total charges and percentage of charges attributable to guideline-endorsed activities. RESULTS: Mean percent documentation of 7 essential items regarding patient history in the medical record increased from 57% during the baseline period to 98% in the intervention phase (42% increase; 95% confidence interval [CI], 34%-49%) and 11 items in aftercare instruction increased from 31 % at baseline to 93% during the intervention phase (62% increase; 95% CI, 51%-74%), but both decreased to baseline when the computer system was removed. Percent compliance with 4 laboratory testing guidelines increased from 63% at baseline to 83% during the intervention phase (20% increase; 95% CI, 9%-31 %) but decreased to 52% when the computer system was removed. Compliance with 5 treatment guidelines increased from 83% at baseline to 96% during the intervention phase (13% increase; 95% CI, 9%-17%) and decreased to 84% following the intervention. Percentage of charges incurred for indicated laboratory tests and treatment increased from 44% at baseline to 81% during the intervention phase (37% increase; 95% CI, 22%-52%) and decreased to 36% following the intervention. Average total per-patient charges were $460, $384, and $373 in each phase, respectively. CONCLUSIONS: Use of a computer-based system for clinical guidelines for management of patients with occupational exposure to body fluids improved documentation, compliance with guidelines, and percentage of charges spent on indicated activities, while decreasing overall charges. The parameters returned to baseline when the computer system was removed.     

Computerized patient record: are we prepared for our future practice?

OBJECTIVE: To survey members of The American Dietetic Association (ADA) regarding care documentation systems, computerization of patient care records, and factors to be considered in developing a documentation system compatible with a computer-based patient record. DESIGN: The survey instrument was developed in conjunction with a survey consultant/statistician, then mailed to the study sample. SUBJECTS/SETTING: The sample of 500 was drawn from three ADA dietetic practice groups expected to include a high percentage of clinical practitioners. STATISTICAL ANALYSIS PERFORMED: Basic frequency displays were used on all questionnaire items. Pearson correlation coefficients were used among numeric variables, and oneway analysis of variance was used for categoric variables with quantitative variables. RESULTS: A total of 171 usable surveys were returned (34%), primarily from dietitians working in an acute-care inpatient environment. The SOAP format (subjective, objective, assessment, and plan) was used by 60% of respondents to document nutrition assessments, although a number of other documentation formats were reported. Most commonly used data in nutrition decision making were medical diagnosis, diet order, anthropometric data, and laboratory values. Most commonly used outcomes measures included laboratory values, tolerance of the nutrition regimen, weight changes, and intake changes. Only 15% of respondents reported that they currently used a computerized patient record. Ninety-three percent of respondents favored standardized nutrition diagnoses, and 95% believed standardized nutrition interventions would prove useful. APPLICATIONS/CONCLUSIONS: We recommend that dietitians evaluate, standardize, and streamline their documentation to prepare for implementation of computerized systems. The diagnoses and interventions presented in this study could be a starting point.     

Requests for complete record release: A three-step response protocol.

Clients seen by therapists sometimes request the release of complete copies of their records to assist them with a variety of problems ranging from personal injury lawsuits, child custody litigation, criminal defense, and other issues. Because clients frequently do not know the contents of their records, release of complete mental health records often creates special problems for therapists and, potentially, for clients alike. This multiple-case study describes the impact of therapist-supervised client chart review, education about client rights, and potential consequences of complete record release on client decisions to maintain or rescind consent to release entire chart records. Participants were 27 current or former clients who submitted requests for release of a complete mental health record. A three part protocol designed to authenticate the request, discuss potential benefits and costs of record release, and read the mental health record was implemented. Subsequent decisions to release or rescind the request were documented. Sixteen of 27 requests were rescinded (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Agreement between administrative files and written medical records: a case of the Department of Veterans Affairs

OBJECTIVES: This study examined the reliability of Department of Veterans Affairs' health information databases concerning patient demographics, use of care, and diagnoses. METHODS: The Department of Veterans Affairs' Patient Treatment files for Main, Bed-section (PTF) and Outpatient Care (OCF) were compared with medical charts and administrative records (MR) for a random national sample of 1,356 outpatient visits and 414 inpatient discharges to Department of Veterans Affairs' facilities between July 1 and September 30, 1995. Records were uniformly abstracted by a focus group of utilization review nurses and medical record coders blinded to administrative file entries. RESULTS: Reliability was adequate for demographics (kappa approximately 0.92), length of stay (agreement=98%), and selected diagnoses (kappa ranged 0.39 to 1.0). Reliability was generally inadequate to identify the treating bedsection or clinic (kappa approximately 0.5). Compared with medical charts, Patient Treatment Files/Outpatient Care Files reported an additional diagnosis per discharge and 0.8 clinic stops per outpatient visit, resulting in higher estimates of disease prevalence (+39% heart disease, +19% diabetes) and outpatient costs (+36% per unique outpatient per quarter). CONCLUSIONS: In the absence of pilot work validating key data elements, investigators are advised to construct health and utilization data from multiple sources. Further validation studies of administrative files should focus on the relation between process of data capture and data validity.     

Electronic medical records: Confidentiality issues in the time of HIPAA.

With the application of the Health Insurance Portability and Accountability Act (HIPAA) in the medical community, new issues arise for psychologists in keeping documented records of patient visits. Confidentiality limits have broadened, making use of the electronic medical record more complicated for the psychologist practitioner, particularly when serving as part of a multidisciplinary team. As the electronic medical record (EMR) has become more prevalent in multiple settings, various researchers have examined the effectiveness of this record keeping system, with a focus on improving patient outcomes. The risks and benefits of implementing an EMR will be discussed, focusing on specific considerations for psychologists in regard to confidentiality and interdisciplinary collaboration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Aging increases CD8 T cell apoptosis induced by hyperstimulation but decreases apoptosis induced by agonist withdrawal in mice

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.     

A study of the services provided by the women's health nurses in a Sydney Area Health Service

OBJECTIVES: To describe the client characteristics and nature of services provided by women's health nurses and to examine whether the goals set for the service are being met. DESIGN: A retrospective study of women's health nurse (WHN) records from 1987 to 1991. SETTING AND SUBJECTS: All women attending the women's health nurse in the Southern Sydney Area Health Service, 1987 to 1991. Older women and women of non English-speaking background are specific targets for this service. OUTCOME MEASURES: Pap test and breast self-examination practices were examined in relation to age and ethnic background. Use of general practitioner services was examined for all women attending the women's health nurse in 1991. RESULTS: Forty-five per cent of clients were aged over 50, and 29 per cent were from a non English-speaking background. Older women were more likely to return for subsequent visits to the women's health nurse. The practice of breast self-examination increased significantly between visits among all women. Forty-one per cent of women had not had a Pap test for at least three years, 93 per cent of these women were screened at their first visit. Eighty-seven per cent of women on their first visit and 86 per cent of women revisiting the women's health nurse had seen their general practitioner within the previous year. CONCLUSION: Women's health nurses are meeting the goals set for their service in relation to health promotion and the screening of women. Their services are perceived by their clients as complementary to those provided by their general practitioners.     

Outcomes of stroke survivors in Yamagata Prefecture

PURPOSE: To clarify the long-term outcomes of Stroke survivors registered for the first onset of Stroke in Yamagata Prefecture and to find out problems in community-based-rehabilitation (CBR). SUBJECTS AND METHODS: The present study was performed using stroke survivors as of September 1, 1991 as subjects from residents registered for the onset of Stroke in 1985 and 1989. The subjects were composed of 1,013 residents registered in 1989 (2 years after onset) and 626 registered in 1985 (6 years after onset). RESULTS: The percent of functionally-independent Stroke survivors at 2 and 6 years (indicated in parentheses) after onset is shown by ADL items as follows: 82% (81%) for urination, 78% (78%) for eating, 78% (78%) for walking, 76% (78%) for dressing, and 66% (64%) for bathing. The lowest percent was seen in Bathing. Percentage of cases maintaining the ability to have functionally-independent ADL for all items examined (expressed as persons independent for personal care) were 62% (60%). Of the the cases 91% (91%) resided at home (their own houses or relatives' houses). With regard to overall locomotion, an item used to evaluation the range of going out doors, 45% (44%) could go out alone to visit neighbors or use public transportation. Among persons independent for personal care, 99% (98%) were living at homo, 70% (69%) used public transportation, 23% (23%) went out alone to visit neighbors and 7% (8%) did not go out. CONCLUSION: The results of the present research indicate a great in CBR for that bothpsychological and social health approaches in cooperation with public health centers, medical centers, and welfare agencies not only for persons with decreased ADL, but also for those maintaining high activity potential.     

The meaning of patient satisfaction: an explanation of high reported levels

The social policy background to the proliferation of patient satisfaction surveys is a desire for increased patient representation and participation. Within this context, it is assumed that satisfaction surveys embody patients' evaluations of services. However, as most surveys report high satisfaction levels, the interpretation of satisfaction as the outcome of an active evaluation has been called into question. The aim of this study is to identify whether and how service users evaluate services. This was made possible through unstructured in-depth interviews with users of mental health services and through more structured discussion around their responses on a patient satisfaction questionnaire (CSQ 18B) whose psychometric properties has been well documented. Twenty-nine people with current or recent contact with mental health services within the British National Health Service were interviewed. The data revealed that service users frequently described their experiences in positive or negative terms. However, the process by which these experiences were transformed into "evaluations" of the service was complex. Consequently, many expressions of "satisfaction" on the CSQ 18B hid a variety of reported negative experiences. An explanation for this lack of correspondence is outlined.