Clinical Documentation System Research Articles

Automating sedation state assessments using natural language processing.

Common goals for procedural sedation are to control pain and ensure the patient is not moving to an extent that is impeding safe progress or completion of the procedure. Clinicians perform regular assessments of the adequacy of procedural sedation in accordance with these goals to inform their decision-making around sedation titration and also for documentation of the care provided. Natural language processing could be applied to real-time transcriptions of audio recordings made during procedures in order to classify sedation states that involve movement and pain, which could then be integrated into clinical documentation systems. The aim of this study was to determine whether natural language processing algorithms will work with sufficient accuracy to detect sedation states during procedural sedation. A prospective observational study was conducted. Audio recordings from consenting participants undergoing elective procedures performed in the interventional radiology suite at a large academic hospital were transcribed using an automated speech recognition model. Sentences of transcribed text were used to train and evaluate several different NLP pipelines for a text classification task. The NLP pipelines we evaluated included a simple Bag-of-Words (BOW) model, an ensemble architecture combining a linear BOW model and a "token-to-vector" (Tok2Vec) component, and a transformer-based architecture using the RoBERTa pre-trained model. A total of 15,936 sentences from transcriptions of 82 procedures was included in the analysis. The RoBERTa model achieved the highest performance among the three models with an area under the ROC curve (AUC-ROC) of 0.97, an F1 score of 0.87, a precision of 0.86, and a recall of 0.89. The Ensemble model showed a similarly high AUC-ROC of 0.96, but lower F1 score of 0.79, precision of 0.83, and recall of 0.77. The BOW approach achieved an AUC-ROC of 0.97 and the F1 score was 0.7, precision was 0.83 and recall was 0.66. The transformer-based architecture using the RoBERTa pre-trained model achieved the best classification performance. Further research is required to confirm the that this natural language processing pipeline can accurately perform text classifications with real-time audio data to allow for automated sedation state assessments. Automating sedation state assessments using natural language processing pipelines would allow for more timely documentation of the care received by sedated patients, and, at the same time, decrease documentation burden for clinicians. Downstream applications can also be generated from the classifications, including for example real-time visualizations of sedation state, which may facilitate improved communication of the adequacy of the sedation between clinicians, who may be performing supervision remotely. Also, accumulation of sedation state assessments from multiple procedures may reveal insights into the efficacy of particular sedative medications or identify procedures where the current approach for sedation and analgesia is not optimal (i.e. a significant amount of time spent in "pain" or "movement" sedation states).

Integrating Battlefield Documentation into Virtual Reality Medical Simulation Training: Virtual Battlefield Assisted Trauma Distributed Observation Kit (BATDOK).

Clinical documentation is an essential component of the provision of medical care, enabling continuity of information across provider and site handoffs. This is particularly important in the combat casualty care setting when a single casualty may be treated by four or more or five completely disparate teams across the roles of care. The Battlefield Assisted Trauma Distributed Observation Kit (BATDOK) is a digital battlefield clinical documentation system developed by the Air Force Research Laboratory to address this need. To support the deployment of this tool, we integrated BATDOK into a commercially available virtual reality (VR) medical simulation platform used by the U.S. Air Force and Defense Health Agency personnel in order to provide an immersive simulation training experience which included battlefield documentation. A multidisciplinary team consisting of medical educators, VR simulation engineers, emergency physicians and pararescuemen, and BATDOK developers first developed a specification for a virtual BATDOK capability, including a detailed listing of learning objectives, critical interfaces and task plans, and sensor integrations. These specifications were then implemented into the commercially available Virtual Advancement of Learning for Operational Readiness VR Medical Simulation System and underwent developmental testing and evaluation during pararescueman training exercises at the Air Force Special Operations Command Special Operations Center for Medical Integration and Development. The BATDOK capability was successfully implemented within the VR Medical Simulation System. The capability consisted of a virtual tablet with replicated interfaces and capabilities based on the developed specifications. These capabilities included integrated point-of-care ultrasound capability, multi-patient management, vitals sign monitoring with sensor pairing and continuous monitoring, mechanism of injury documentation (including injury pattern documentation), intervention logging (including tourniquets, dressing, airways, lines, tubes and drains, splints, fluids, and medications), and event logging. The capability was found to be operational and in alignment with learning objectives and user acceptance goals.

Design and Implementation of a Collaborative Clinical Practice and Research Documentation System Using SNOMED-CT and HL7-CDA in the Context of a Pediatric Neurodevelopmental Unit

This paper introduces a prototype for clinical research documentation using the structured information model HL7 CDA and clinical terminology (SNOMED CT). The proposed solution was integrated with the current electronic health record system (EHR-S) and aimed to implement interoperability and structure information, and to create a collaborative platform between clinical and research teams. The framework also aims to overcome the limitations imposed by classical documentation strategies in real-time healthcare encounters that may require fast access to complex information. The solution was developed in the pediatric hospital (HP) of the University Hospital Center of Coimbra (CHUC), a national reference for neurodevelopmental disorders, particularly for autism spectrum disorder (ASD), which is very demanding in terms of longitudinal and cross-sectional data throughput. The platform uses a three-layer approach to reduce components' dependencies and facilitate maintenance, scalability, and security. The system was validated in a real-life context of the neurodevelopmental and autism unit (UNDA) in the HP and assessed based on the functionalities model of EHR-S (EHR-S FM) regarding their successful implementation and comparison with state-of-the-art alternative platforms. A global approach to the clinical history of neurodevelopmental disorders was worked out, providing transparent healthcare data coding and structuring while preserving information quality. Thus, the platform enabled the development of user-defined structured templates and the creation of structured documents with standardized clinical terminology that can be used in many healthcare contexts. Moreover, storing structured data associated with healthcare encounters supports a longitudinal view of the patient's healthcare data and health status over time, which is critical in routine and pediatric research contexts. Additionally, it enables queries on population statistics that are key to supporting the definition of local and global policies, whose importance was recently emphasized by the COVID pandemic.

Development and application of an electronic synoptic report for reporting and management of low-dose computed tomography lung cancer screening examination

BackgroundInterpretation of Low Dose CT scans and protocol driven management of findings is a key aspect of lung cancer screening program performance. Reliable and reproducible methods are needed to communicate radiologists’ interpretation to the screening program or clinicians driving management decision.MethodsWe performed an audit of a subset of dictated reports from the PANCAN study to assess for omissions. We developed an electronic synoptic reporting tool for radiologists embedded in a clinical documentation system software. The tool was then used for reporting as part of the Alberta Lung Cancer Screening Study and McGill University Health Centre Pilot Lung Cancer Screening Program.ResultsFifty reports were audited for completeness. At least one omission was noted in 30 (70%) of reports, with a major omission (missing lobe, size, type of nodule in report or actionable incidental finding in recommendation section of report) in 24 (48%). Details of the reporting template and functionality such as automated nodule cancer risk assessment, Lung-RADS category assignment, auto-generated narrative type report as well as personalize participant results letter is provided. A description of the system’s performance in its application in 2815 CT reports is then summarized.ConclusionsWe found that narrative type radiologist reports for lung cancer screening CT examinations frequently lacked specific discrete data elements required for management. We demonstrate the successful implementation of a radiology synoptic reporting system for use in lung cancer screening, and the use of this information to drive program management and communications.

Outcome oriented clinical research and quality measurement in fracture care

Abstract Objective The paradigm shift according to the principles of Value-Based Healthcare is receiving growing attention. In Orthopedic Trauma care, there are no defined standards to provide an incentive system to recompensate for quality instead of quantity. The definitions of quality from the patient's view have to be validated and included in the reimbursement cycle. In our Department, we now have fully standardized and structured documentation and outcome measurement workflow from the clinical point of view. Methods We set up a Fracture Registry with a REDCap® Database to document every patient with surgical treatment. Included are all surgically treated fractures of the extremities, excluding the hand. Furthermore pelvic, acetabular, and periprosthetic fractures, joint dislocations, and tendon ruptures. With interfaces to our Clinical Documentation Systems, the administrative effort became very efficient. The interfaces provide a possibility to identify every patient with inclusion criteria and implement reminder feedback for Surgeons. We collect PROMs with the heartbeat-Software, and document CROMs with REDCap®. We merged these data using the software ‘R’. The documentation of each patient is completed with a database for Adverse Events. Results Data-entry rates were less than 50% in 2018 and have reached 99.1% for 2020 and 99.5% for 2021 for surgically treated fracture patients. Until the submission of this abstract, 2382 surgical procedures have been performed at our Department on 2073 hospitalized patients. 972 patients were included in the Fracture Registry (47%). In a feasibility study, we have merged clinical data with the PROMs of patients treated for distal radius (DR) and proximal humerus (PH) fractures. The baseline values for DR of the quality-of-life questionnaire EQ5D was 0.83 (n=144), after 3months 0.9 (n=58) and 0.97 one year after treatment (n=6). Although not more than a trend, we realized the same pattern for PH-patients with an EQ5D-Baseline of 0.75 (n=63), three months values of 0.75 (n=58), and one-year results of 0.87 (n=6). Conclusion Collecting structured data allows combining routine clinical data with PROMs and CROMs. This information is of inestimable value to define the quality of care for Orthopedic Trauma Surgery. Our combination of Databases to collect diagnosis, subjective and objective outcome measures has been proven feasible and showed high data quality.

The implementation of scribing within a medical school\u2019s pre-clinical curriculum: pilot study

BackgroundMedical students matriculating from their preclinical curriculum into clinical clerkships face a significant learning curve when using an electronic medical record (EMR) system for clinical documentation. With the trend toward reduction in preclinical medical education, students now have fewer opportunities to optimize their note-writing and overall clinical skills before transitioning to patient-care settings.MethodsThis study sought to investigate how a structured medical scribing program in an outpatient clinic helps bridge the gap between traditional preclinical and clinical curricula in medical education. A small cohort of medical students were trained in medical scribing within our institutions’ existing preclinical preceptorship program. We surveyed students, preceptors, and patients during the project to better understand confidence around documentation, the EMR, and the impact of the scribing program on workflow efficiency and patient satisfaction.ResultsThere was no significant difference between the scribe and non- scribe students in their confidence documenting a patient encounter or navigating EMR (all p > .05). Our study demonstrated that preceptors for scribe students reported a significant decrease in documentation time compared to non-scribes (Mdiff = − 5.75, p = .02), with no negative impact on patient satisfaction.ConclusionsMedical scribing can be a tool to further develop medical trainees in clinical documentation and help prepare them for the responsibilities during clinical years. When summing the per encounter time savings over the course of a half or full clinic day, scribing can return a significant amount of time back to preceptors. The time saved by the preceptor needs to be further investigated to determine if the time can lend itself towards better patient care, student-specific feedback, focused teaching, or even mentoring.

Developing machine learning-based models to help identify child abuse and neglect: key ethical challenges and recommended solutions.

Child abuse and neglect are public health issues impacting communities throughout the United States. The broad adoption of electronic health records (EHR) in health care supports the development of machine learning-based models to help identify child abuse and neglect. Employing EHR data for child abuse and neglect detection raises several critical ethical considerations. This article applied a phenomenological approach to discuss and provide recommendations for key ethical issues related to machine learning-based risk models development and evaluation: (1) biases in the data; (2) clinical documentation system design issues; (3) lack of centralized evidence base for child abuse and neglect; (4) lack of "gold standard "in assessment and diagnosis of child abuse and neglect; (5) challenges in evaluation of risk prediction performance; (6) challenges in testing predictive models in practice; and (7) challenges in presentation of machine learning-based prediction to clinicians and patients. We provide recommended solutions to each of the 7 ethical challenges and identify several areas for further policy and research.

Development and evaluation of an electronic nursing documentation system

BackgroundNursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reports are described in scientific literature and care practice, and no uniform structured documentation is provided. This study aimed to describe the process of designing and evaluating the content of an electronic clinical nursing documentation system (ECNDS) to provide consistent and unified reporting in this context.MethodsA four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisted of two phases, as follows: First, a literature review was performed to attain an exhaustive overview of the relevant elements of nursing and map the available evidence underpinning the development of the MDS. Then, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Afterward, the ECNDS was developed according to the finalized MDS, and eventually, its performance was evaluated by involving the end-users.ResultsThe proposed MDS was divided into administrative and clinical sections; including nursing assessment and the nursing diagnosis process. Then, a web-based system with modular and layered architecture was developed based on the derived MDS. Finally, to evaluate the developed system, a survey of 150 registered nurses (RNs) was conducted to identify the positive and negative impacts of the system.ConclusionsThe developed system is suitable for the documentation of patient care in nursing care plans within a legal, ethical, and professional framework. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.

User interface approaches implemented with automated patient deterioration surveillance tools: protocol for a scoping review

IntroductionEarly identification of patients who may suffer from unexpected adverse events (eg, sepsis, sudden cardiac arrest) gives bedside staff valuable lead time to care for these patients appropriately. Consequently, many...

Physicians’ perceptions about narrative note sections format and content: A multi-specialty survey

ObjectiveTo assess physicians’ perceptions about narrative note sections format and content commonly reported in visit notes to inform future research and EHR development. MethodsWe conducted two online surveys with a multi-specialty panel of outpatient physicians from a large health system to collect their perceptions of the usefulness of three narrative formats and the relevance of content reported in the note sections history of present illness (HPI) and assessment and plan (AP). Survey questions were responded with a 7-point Likert scale and include two open-ended questions for comments on challenges and suggestions related to electronic clinical documentation. ResultsEighty-eight physicians completed the surveys. The most preferred format for HPI was story (i.e., coherent paragraph), followed by list without categories (i.e., non-categorized sentences) and list with categories (i.e., categorized sentences). The most preferred format for AP was list with categories, followed by story and list without categories. The most relevant type of content in HPI was temporal information and finding/condition. The most relevant type of content reported in AP was intervention and reasons and justifications. Challenges frequently mentioned include suboptimal note creation interfaces and bloated notes, and the most common suggestions for improvements are related to note entry facilitators and organizational improvements. ConclusionPhysicians’ input is extremely valuable to inform improvements to EHRs. More effective clinical documentation systems should include less intrusive, more intuitive and automated user interfaces for note creation, smarter autopoluation functionality and linkage between note content and data from other parts of the record.

Tracking of Clinical Documentation Based on the Blockchain Technology—A Polish Case Study

The article presents the concept of application DLT (distributed ledger technologies) for building the electronic clinical documentation tracking system. After a short introduction to block chain issues, and discussion about the attempts of its application on various fields of everyday human life, including healthcare, basic requirements for tracking of clinical documentation system are presented, followed by the proposition of its architecture leveraging the distributed ledger technologies. The paper is concluded with a discussion about the possibilities of running such a system, regarding constraints coming from local legal regulations and general data protection regulation (GDPR), but also economic and social conditions, including ecological ones, which are part of the sustainable development trend.

EHealth and Clinical Documentation Systems.

eHealth is the use of modern information and communication technology (ICT) for trans-institutional healthcare purposes. Important subtopics of eHealth are health data sharing and telemedicine. Most of the clinical documentation to be shared is collected in patient records to support patient care. More sophisticated approaches to electronic patient records are trans-institutional or (inter-)national. Other aims for clinical documentation are quality management, reimbursement, legal issues, and medical research. Basic prerequisite for eHealth is interoperability, which can be divided into technical, semantic and process interoperability. There is a variety of international standards to support interoperability. Telemedicine is a subtopic of eHealth, which bridges spatial distance by using ICT for medical (inter-)actions. We distinguish telemedicine among healthcare professionals and telemedicine between health care professionals and patients. Both have a great potential to face the challenges of aging societies, the increasing number of chronically ill patients, multimorbidity and low number of physicians in remote areas. With ongoing digitalization more and more data are available digitally. Clinical documentation is an important source for big data analysis and artificial intelligence. The patient has an important role: Telemonitoring, wearable technologies, and smart home devices provide digital health data from daily life. These are high-quality data which can be used for medical decisions.

Identifying essential clinical skills and procedures for FNP students using an electronic clinical documentation system.

Nurse practitioner (NP) education is designed to prepare graduates for competent entry-level practice. However, many new family NPs (FNPs) report a lack of preparation in performing clinical skills and procedures (CSPs). There is no approved list of CSPs for FNP students. Further, there is a dearth of literature reporting CSPs frequently performed by NPs to guide NP curricula development. The purpose of this investigation was to summarize frequently encountered CSPs reported by students enrolled in an FNP program from August 2012 through December 2018 at a Midwest university and to compare results with those found in the literature. After a comprehensive review of literature, a retrospective, longitudinal assessment of CSPs identified by FNP students and extracted from a proprietary, electronic clinical documentation system (eLOGS) was conducted. Comparison was made with current literature on CSPs used by practicing FNPs. Overall, there was consistency between CSPs documented by students in eLOGS and those found in the literature. Unique to this investigation was the frequent reporting of behavioral health assessments by students. Because behavioral health conditions are often first diagnosed and treated in the primary care setting, competency in care of behavioral health conditions is clearly a necessary CSP. Educators have a responsibility to prepare graduates for the skill set needed in the workplace. This includes a standardized set of CSPs essential to FNP practice. Development of a universally accepted list of CSPs will be instrumental in refining evidence-based NP curricula that best prepares graduates with the experience and confidence necessary to enter practice.

Posters (P)

BACKGROUND: Full assessment of patients with (occupational) contact dermatitis should ideally include a standardized investigation of irritant exposures in addition to information pertaining to possible allergy guiding the selection of allergens (haptens) to be tested. Positive results of skin tests, performed according to current guidelines, are evaluated in terms of their clinical relevance. However, such diagnostic information is hitherto ill-represented in clinical documentation systems (patch test software) serving departmental documentation needs, and also in surveillance registries based upon these. OBJECTIVES: To develop, implement as a pilot study, and analyse concerning feasibility and contents a new concept of representing a full scope of diagnostic information utilized when diagnosing patients with (occupational) contact dermatitis. METHODS: Based on a European working group discussion on items to document and catalogue lists to use for this purpose, an online documentation system to collect data was set up, followed by a pilot use involving 9 dermatology departments across Europe. RESULTS: Data on 176 patients with suspected occupational hand dermatitis were included. Data were analysed with regard to occupations, product categories, substances (haptens), source of information the evaluation was based upon, and various combinations of these factors, to illustrate the usefulness of the proposed data representation. CONCLUSIONS: An improved method of data collection is presented which more accurately links allergen to exposure and to clinical disease and patient history, and thus better represents clinical relevance. This enables more precise analysis of causation of contact dermatitis, occupational or non-occupational, and thereby better targeting of prevention on an individual basis. In addition to the benefits for individual documentation, the surveillance of contact dermatitis is expected to be enhanced by the suggested concept, allowing a more in-depth investigation of profiles of patients at risk for certain allergies, while still serving other well-proven purposes, eg time trend analyses.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

Advancing Rehabilitation Practice Through Improved Specification of Interventions

Rehabilitation clinicians strive to provide cost-effective, patient-centered care that optimizes outcomes. A barrier to this ideal is the lack of a universal system for describing, or specifying, rehabilitation interventions. Current methods of description vary across disciplines and settings, creating barriers to collaboration, and tend to focus mostly on functional deficits and anticipated outcomes, obscuring connections between clinician behaviors and changes in functioning. The Rehabilitation Treatment Specification System (RTSS) is the result of more than a decade of effort by a multidisciplinary group of rehabilitation clinicians and researchers to develop a theory-based framework to specify rehabilitation interventions. The RTSS describes interventions for treatment components, which consist of a target (functional change brought about as a direct result of treatment), ingredients (actions taken by clinicians to change the target), and a hypothesized mechanism of action, as stated in a treatment theory. The RTSS makes explicit the connections between functional change and clinician behavior, and recognizes the role of patient effort in treatment implementation. In so doing, the RTSS supports clinicians’ efforts to work with their patients to set achievable goals, select appropriate treatments, adjust treatment plans as needed, encourage patient participation in the treatment process, communicate with team members, and translate research findings to clinical care. The RTSS may help both expert and novice clinicians articulate their clinical reasoning processes in ways that benefit treatment planning and clinical education, and may improve the design of clinical documentation systems, leading to more effective justification and reimbursement for services. Interested clinicians are invited to apply the RTSS in their local settings.

Electronic documentation for Health and Social Care Professionals: The patient perspective

Introduction & Practice Change : The Health and Social Care professions (HSCPs) comprising of physiotherapy (PT), occupational therapy (OT), medical social work MSW), clinical nutrition (CN) and speech and language therapy (SLT) in St. James’s hospital together with the IT department, have designed and implemented an electronic clinical documentation system aimed at replacing paper-based documentation for these professions. This is in line with national and organizational strategic aims towards a complete electronic patient record. Aim : To examine the patient’s perspective on electronic documentation, to proactively address their concerns and expectations of the system. Targeted population : Patients from inpatient and outpatient settings across a variety of clinical areas were surveyed. The questionnaire included demographics, patients views on the security and efficiency of electronic vs paper based documentation, their preferred method of documentation and open questions for comments or suggestions they had regarding the use of electronic documentation. The inclusion criteria were; actively being treated by a therapist, the ability to understand questions and verbalise responses. The results were then entered into Microsoft Excel for analyses and performance of simple descriptive statistics. Timeline : August 2016 Highlights : 94 participants completed the survey (PT=20; OT=16; MSW=17; CN=21; SLT=20), comprising 44 inpatients and 50 outpatients. 32% (n=33) were over 65years of age. 41% (n=39) were male. 86% of participants (n=81) felt that electronic documentation was as secure or more secure than paper notes, while 95% (n=89) felt that electronic documentation was efficient or more efficient than paper notes. 45% (n=42) preferred electronic documentation, 25% (n=24) preferred paper while 30% (n=28) had no preference. Themes emerging from patients comments were mainly positive. Many remarked on efficiency and convenience. However patients expressed concerns over potential hacking and access to their documents. Sustainability & Transferability : The use of electronic documentation has been perceived positively by patients surveyed. 94% of patients identified efficiency as an advantage to this style of documentation. Their concerns regarding the security should be addressed by disclosing this information in an open manner. The information gained will be fed back through the hospital's information governance committee and a list of FAQs will be gvien to patients.

Effect of a Multimodal Educational Intervention on Use of Urinary Catheters in Hospitalized Individuals

Urinary catheters are frequently used in hospital inpatients despite their association with greater morbidity and mortality. Reducing their unnecessary use can improve patient care. The objective of the current study was to determine the effectiveness of a multimodal nursing and physician education intervention to reduce the unnecessary use of urinary catheters in adult inpatients. Quasi-experimental interrupted time series study. General internal medicine and surgical services of a large urban teaching hospital. Admissions to the services under study during the study period (September 2009 to February 2013) (N = 21,550). A multimodal educational intervention incorporating educational posters, small-group teaching sessions, and changes to the hospital's electronic health records and nursing clinical documentation systems were introduced to nurses and physicians. Mean catheter days per patient (CDPP) and incidence of urinary catheterization, measured at monthly intervals throughout the study period. A decrease in mean CDPP of 5.6 and 6.5 days (P < .001) respectively was observed on the medical and surgical services following the intervention. The monthly incidence of catheterization decreased by 3.0 percentage points on medical units and 6.4 percentage points on surgical units immediately after the intervention, from an average of 14.5% and 15.0%, respectively, before the intervention. Similar degrees of improvement were observed for individuals of all ages, although older adults remained more likely to be catheterized. The effect persisted over nearly 3 years of observed follow-up. A relatively simple multimodal educational intervention targeting nurses and physicians resulted in a significant and sustained reduction in CDPP and the proportion of participants catheterized.

Integrating cancer genomic data into electronic health records.

The rise of genomically targeted therapies and immunotherapy has revolutionized the practice of oncology in the last 10–15 years. At the same time, new technologies and the electronic health record (EHR) in particular have permeated the oncology clinic. Initially designed as billing and clinical documentation systems, EHR systems have not anticipated the complexity and variety of genomic information that needs to be reviewed, interpreted, and acted upon on a daily basis. Improved integration of cancer genomic data with EHR systems will help guide clinician decision making, support secondary uses, and ultimately improve patient care within oncology clinics. Some of the key factors relating to the challenge of integrating cancer genomic data into EHRs include: the bioinformatics pipelines that translate raw genomic data into meaningful, actionable results; the role of human curation in the interpretation of variant calls; and the need for consistent standards with regard to genomic and clinical data. Several emerging paradigms for integration are discussed in this review, including: non-standardized efforts between individual institutions and genomic testing laboratories; “middleware” products that portray genomic information, albeit outside of the clinical workflow; and application programming interfaces that have the potential to work within clinical workflow. The critical need for clinical-genomic knowledge bases, which can be independent or integrated into the aforementioned solutions, is also discussed.Electronic supplementary materialThe online version of this article (doi:10.1186/s13073-016-0371-3) contains supplementary material, which is available to authorized users.

The American College of Nurse-Midwives Clarity in Collaboration Project: Describing Midwifery Care in Interprofessional Collaborative Care Models.

In 2014, the American College of Nurse-Midwives (ACNM) launched a project called Clarity in Collaboration to develop data definitions related to midwifery and maternity care delivery processes. These definitions are needed to ensure midwifery care delivered in collaborative care models is accurately and consistently captured in clinical documentation systems, data registries, and systems being developed as part of health care restructuring and payment reform. The Clarity in Collaboration project builds on the efforts of the Women's Health Registry Alliance (WHRA), which was recently established by the American College of Obstetricians and Gynecologists. Clarity in Collaboration mirrored the process used by ReVITALize, WHRA's first maternity data standardization project, which focused on establishing standardized clinical data definitions for obstetrics. The ACNM Clarity in Collaboration project brought together maternity and midwifery care experts to complete a year-long consensus process, including a period of public comment, resulting in development of 20 concept definitions. These definitions can be used to describe midwifery care within the context of collaborative care models. This article provides a summary of the ACNM Clarity in Collaboration process with discussion of implications for maternity data collection.