Computer-based Patient Record Research Articles

Electronic Health File System based on Fingerprint Sensor Technology

In medical sector, the use of computers and information technology helps in diagnosis, especially the computer-based patient record (CPR). As the traditional method of storing patient files is not feasible to obtain the health file, especially those who are in critical conditions, such as accidents, loss of consciousness and memory at times, due to the consumption of a lot of time and effort in the process of manual searching in traditional files. In order to help health care centers quickly identify patient personal data and make accurate decisions, an automated electronic system for patient health files based on a fingerprint sensor was built using special methods and technologies such as Content-Based Image Retrieval (CBIR) system, which is a retrieval technology based on the similarity of the images has the potential to facilitate identification and diagnosis of the patient's condition when he or she is unconscious. This study aims to integrate different technologies and discuss issues related to the electronic health file system based on the patient's fingerprint data, the use of (fingerprint sensor) technology, linking to the patient file data system, storage in fingerprint databases, and health data for each. sick.; To help critical cases, in addition to applying this technology and employing it in the ambulance and diagnostic system in order to improve the level of medical services and reach the desired results. The results showed that the electronic health profile was successfully built, designed and implemented for its intended purpose, the system and the destinations that connect users to the system as well as the fingerprint sensor. Finally, the system is efficient and gives reliable results with up to 100% tested accuracy based on the states it was stored.

Association of the 1236C>T variant of the multidrug resistance 1 gene with esophageal squamous cell carcinoma development and prognosis

BackgroundEsophageal squamous cell carcinoma (ESCC) is a common cause of cancer related mortality. There is a growing body of evidence showing an association between genetic variants in the 7q21.12 gene locus and an increased risk of cancer. Here we have explored the association between the 1236C > T; rs1128503 genetic variant of the ABCB1/ MDR1 gene with the development and prognosis of ESCC. MethodData from the computer-based patient records (CPRs) of 10 years (between 2006 and 2014) of the Mashhad University of Medical Sciences were used to identify patients with ESCC. Ninety-three ESCC patients and two hundred and twenty-four healthy subjects were recruited. DNA was extracted and genotyped using a Taq-Man based real-time PCR method. The association of the variant with overall-survival (OS) and progression-free survival (PFS) was analyzed using Kaplan–Meier curves, log-rank tests, and Cox model. ResultsPatients with ESCC had a higher frequency of the C allele compared to the control group with MAF of 1.5. Moreover, 22%, and 56% of cases had TT and TC genotypes, compared to 22% for CC. Patients with TT genotype, versus CC had a higher risk of ESCC (OR: 2.3; 95%CI: 1.08–4.8, P = 0.03), although it was not associated with PFS and OS (e.g., OS of TT genotype: 56.8 ± 6.9 months versus OS of CC genotype: 60.5 ± 5.7 months). ConclusionWe have investigated the relationship between a genetic polymorphism of the ABCB1 gene with clinical outcomes of the ESCC-patients, supporting further studies in a larger, and multi-centre settings followed by functional assays to assess the prognostic value of this emerging marker in esophageal squamous cell carcinoma patients.

Virtuosic craft or clerical labour: the rise of the electronic health record and challenges to physicians’ professional identity (1950–2022)

The electronic health record (EHR) is a focus of contentious debate, having become as essential to contemporary clinical practice as it is polarising. Debates about the EHR raise questions about...

Antithrombotic therapy in coronary artery disease patients with atrial fibrillation

BackgroundCoronary artery disease (CAD) and atrial fibrillation (AF) frequently coexist in clinical practice, making it challenging for the treating physician to choose anticoagulation and antiplatelet therapies. The aim of this study was to investigate antithrombotic strategies and assess related adverse outcomes in stable coronary artery disease (SCAD) and acute coronary syndrome (ACS) patients with AF when the CHA2DS2-VASc score was ≥2.MethodsWe performed a retrospective study and collected data from a computer-based patient record management system in Zhengzhou University People’s Hospital in China. In total, 2978 patients with a hospital discharge diagnosis of CAD and concomitant AF who met the inclusion criteria were enrolled from January 1, 2012 to December 31, 2016, and data from 2050 patients were finally analysed. The χ2 test was used to compare the incidences of clinical endpoints between the SCAD+AF group and the ACS + AF group. Multivariable Cox regression analysis was performed to identify independent predictive factors of adverse outcomes in both groups.ResultsOral anticoagulant (OAC) monotherapy was the most common antithrombotic therapy in SCAD+AF patients (49.55%), while double antiplatelet therapy (DAPT) was the most common treatment in ACS + AF patients (54.19%) at discharge. OAC monotherapy significantly increased and the use of single antiplatelet therapy (SAPT) decreased during follow-up (34 ± 13 months) when compared to their use at discharge in the SCAD+AF group (all p < 0.001). In the ACS + AF group, the proportion of patients using DAPT decreased notably, while the proportions of patients using SAPT and dual therapy (DT) combining OAC with SAPT increased significantly during follow-up (all p < 0.001) compared to the proportions at discharge. According to multivariable Cox regression analysis, age, hypertension and prior stroke were independent risk factors for ischaemic stroke in the SCAD+AF group and ACS + AF group (all p < 0.05). OAC was an independent protective factor for ischaemic stroke in both groups (all p < 0.05). Previous bleeding independently increased the risk of haemorrhage in both groups (all p < 0.01).ConclusionsIn this study, the proportion of anticoagulant-antiplatelet combined therapy was low in ACS + AF patients with high stroke risk. In clinical practice, the awareness of anticoagulation needs to be strengthened regarding patients with CAD and AF.

The Association Between Hyperparathyroidism and Ischemic Stroke Subtypes

Background: Up to date, a substantial amount of research has remarked on the potential role of parathormone (PTH) in the development of subclinical and clinical vascular diseases. However, the association between the hyperparathyroidism and cerebrovascular disease has rather been underestimated in the literature. Herein, we aimed to investigate the association between serum PTH levels and ischemic stroke. Methods: Serum PTH levels were measured in all patients with ischemic stroke who were hospitalized in the Yozgat City Hospital between January 1, 2017 and January 1, 2019. Clinical and demographic findings were retrospectively evaluated via computer-based patient record system of Yozgat City Hospital (AKGUN). Results: Overall, 158 patients with ischemic stroke with a median age of 71.5 ± 11.5 were enrolled in this study. Parathyroid hormone was found to be high in 31 of the patients (19.6%). The stroke subtype of extracranial atherosclerosis was found to be more common in the group of patients with a high level of PTH (12%/3%; P = 0.008). Remarkably, logistic regression analyses also confirmed that high PTH level was a significant variable in the determination of the stroke subtype of extracranial atherosclerosis (P = 0.024). Conclusions: We have found a high rate of hyperparathyroidism in our group of patients with ischemic stroke. Remarkably, the elevation of PTH was found to be significantly associated with the ischemic stroke subtype of extracranial atherosclerosis. Clarification of these results in the future large-scale studies may provide crucial perspectives regarding our understanding of the pathophysiology of some subtypes of ischemic stroke and potentially lead to a large public health implication in this area. J Neurol Res. 2020;10(1):7-12 doi: https://doi.org/10.14740/jnr564

Telemedicine Tools for Patients and Providers: Systematic Review

Background: From the 1991 Institute of Medicine (IOM) Landmark Report, The Computer Based Patient Record: An Essential Technology for Health Care (Dick, Steen, & Detmer, 1997) which called for computer based patient records, to the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, health care has been integrating technology into our delivery systems and transforming the landscape of health care delivery (Wager, Lee, & Glaser, 2017). Telemedicine (also called telemonitoring, telehealth, remote monitoring, eHealth) has brought about new methods of care delivery. These methods will hopefully demonstrate cost effective outcomes as well as new levels of quality. Under the influence of The Centers for Medicare and Medicaid Services, The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) was enacted which pushes the health care industry to improve quality and value. By the end of 2018, it is expected that 50% of alternative payment models will have quality and value tied to them and 90% of fee-for-service will do the same. It is feasible that telehealth could be the link to new health care delivery and payment models. This paper evaluates some of the most recent literature regarding telemedicine to elucidate quality within the domains of cost-effectiveness, hospitalization, mortality, patient adherence, and patient satisfaction. Objective: To evaluate the effectiveness of telemedicine strategies with respect to cost-effectiveness of care, hospitalizations, mortality, patient adherence, and satisfaction. Methods: The Google Scholar search engine was used to find articles published between 2015 and 2018 so that preliminary observations could be made regarding the telemedicine literature. Once this was done, a logical search process was used to locate articles using two research databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed (MEDLINE). The titles and abstracts of the records identified were independently screened by four investigators. Five reviewers screened 58 abstracts to determine relevance and significance relative to the research objectives. The final group analysis was 29 articles. Main outcome measures included economic, clinical, and satisfaction outcomes. Results: Our results showed that examining telemedicine interventions that were either patient or provider driven appeared to improve outcomes related to patient adherence, patient satisfaction, cost-effectiveness, and had a favorable effect in terms of decreasing hospitalizations. Only two articles that were reviewed addressed mortality, so the investigators could not describe results on its effect. Although there are barriers to adherence there is much progress in the field of telemedicine that aids in outcomes, both positive and negative. Conclusions: The literature is clear that telemedicine is linked to improved outcomes when applied with a sound strategic plan. Patients who adhere to telemedicine interventions appear to show significantly better satisfaction, quality of life, reduced hospitalizations, and related health care costs. When providers take greater responsibility and initiative with telemedicine interventions, this contributes to those patient outcomes. Our review of the literature suggests that the quality of the implementation strategy was linked with better outcomes. Telemedicine appears to hold promise as a cost effective, convenient tool for both patients and providers.

Hadoop Map Only Job for Enciphering Patient-Generated Health Data

Today, Big Data is being leveraged in many industries from criminal justice to health care to real estate with powerful outcomes. Organizations are using Big Data to predict the future in turn making them smarter and efficient. All the health care data such as discharge and transfer patient data maintained in Computer based Patient Records (CPR), Personal Health Information (PHI), and Electronic Health Records (EHR). The use of Big Data analytics is becoming increasingly popular at health care centres, in clinical research, and consumer based medical product development. The biggest challenge with implementation of big data is that the nature of information of public health sector is of very sensitive nature and needs to be protected from unauthorized access and release of contents. Therefore, to provide solution to the deidentifying personal health big data in this paper we author make use of only mapper job framework for data encryption.

245P SOX15 expression was associated with poor prognosis in patients with esophageal squamous cell carcinoma: An Iranian cohort study conducted over 10 years

Background WNT/B-CATENIN signaling pathway is one of the key dysregulated pathways in esophageal squamous cell carcinoma (ESCC), which has been reported to be modulated by sex-determining region Y-box (SOX) family genes. SOX15 is recently been identified as a novel tumor suppressor in pancreatic cancer with a potential role in modulating Wnt/b-catenin signaling. The aim of current study was to explore, for the first time, the expression pattern of SOX15 in an Iranian patient cohort with ESCC. Methods Data in computer-based patient records (CPRs) of Mashhad University of Medical Sciences were used to retrieve all ESCC patients, during July 2004 to September 2014, from Khorasan providence, the second big providence of Iran. Based on the available tissue, one hundred and eight patients were recruited for current study. The stained sections were micro-dissected under a microscope, followed by RNA extraction. The expression pattern of Sox15 was evaluated by real time RT-PCR. Demographic and clinical information were compared across genotype using Pearson tests. OS and PFS curves were analyzed according to Kaplan-Meier method, and compared by log-rank and Wilcoxon tests. The significant prognostic variables in the univariate analysis were included in multivariate analyses, using Cox's proportional hazards model Results Our data showed that patients with low mRNA expression of SOX15 had statistically significantly shorter survival (eg, mean = 43.5 months, 95% confidence interval [CI] = 4.4to52.6;vsmean=58.1 months, 95% CI = 56.2to80.1;P = 0.04,two-sidedlog- rank test), and multivariable analyses confirmed prognostic relevance of this marker in the patient.Inparticular,SOX15downregulationwassignificantlyassociatedwithriskofdeath (hazardratio,HR=1.6,95%confidenceinterval[CI],1.2-2.6)inourpopulation. Conclusions These results define SOX15 as a novel prognostic factor for ESCC. Further functional analysis is warranted to determine its tumor-suppressor role in ESCC Legal entity responsible for the study N/A Funding Mashhad University of Medical Sciences Disclosure All authors have declared no conflicts of interest.

Informed Consent

Despite efforts to provide standard definitions of terms such as "medical record", "computer-based patient record", "electronic medical record" and "electronic health record", the terms are still used interchangeably. Initiatives like data and information governance, research biorepositories, and learning health systems require availability and reuse of data, as well as common understandings of the scope for specific purposes. Lacking widely shared definitions, utilization of the afore-mentioned terms in research informed consent documents calls to question whether all participants in the research process - patients, information technology and regulatory staff, and the investigative team - fully understand what data and information they are asking to obtain and agreeing to share. This descriptive study explored the terminology used in research informed consent documents when describing patient data and information, asking the question "Does the use of the term "medical record" in the context of a research informed consent document accurately represent the scope of the data involved?" Informed consent document templates found on 17 Institutional Review Board (IRB) websites with Clinical and Translational Science Awards (CTSA) were searched for terms that appeared to be describing the data resources to be accessed. The National Library of Medicine's (NLM) Terminology Services was searched for definitions provided by key standards groups that deposit terminologies with the NLM. The results suggest research consent documents are using outdated terms to describe patient information, health care terminology systems need to consider the context of research for use cases, and that there is significant work to be done to assure the HIPAA Omnibus Rule is applied to contemporary activities such as biorepositories and learning health systems. "Medical record", a term used extensively in research informed consent documents, is ambiguous and does not serve us well in the context of contemporary information management and governance.

Incidence and prevalence of lupus in Buenos Aires, Argentina: a 11-year health management organisation-based study

ObjectivesStudies regarding the epidemiology of systemic lupus erythematosus (SLE) are lacking in Argentina. Our purpose was to estimate the incidence and prevalence of SLE in a university hospital-based health management...

Enrichment/Population of Customized CPR (Computer-Based Patient Record) Ontology from Free-Text Reports for CSI (Computer Semantic Interoperability)

CSI (Computer Semantic Interoperability) is a very important issue in healthcare. Ways for heterogeneous computer systems to “understand” important facts from the clinical process for clinical decision support are now beginning to be addressed. The authors present here comprehensive contributions to achieve CSI. EHR (Electronic Health Record) systems provide a way to extract reports of the clinicians activity. In order to formalize an automated acquisition from semi-structured, free-form, natural language texts in Portuguese into a Clinical Practice Ontology an important step is to develop the ability of decoding all the nicknames, acronyms and short-hand forms that each clinician tend to write down in their reports. The authors present the steps to develop clinical vocabularies extracting directly from clinical reports in Portuguese available in the SAM (Sistema de Apoio ao Médico) system. The presented techniques are easily further developed for any other natural language or knowledge representation framework with due adaptations.

An Indeterminacy Temporal Data Model Based on Probability

There are many kinds of indeterminacy temporal data in temporal database. Therefore, many researchers have focused on building indeterminacy temporal data models. Unfortunately, established models can’t adequately address the challenges posed by indeterminacy temporal information, and can’t adapt to all sorts of involved applications. In this paper, we propose a temporal data model, named BPTM (Temporal model based on probability), to manage the indeterminacy temporal semantics of indeterminacy data. Firstly, we present our tuple-timestamp method to represent and store these temporal data including determinacy and indeterminacy data. Then we introduce the temporal primitives to process temporal relations needed in BPTM. A new probability method is brought forward to get potential information among these indeterminacy data. At last a query example based on CPR (Computer-based Patient Record) is given to show that our method is effective and feasible. DOI: http://dx.doi.org/10.11591/telkomnika.v11i11.3516

Enrichment/Population of Customized CPR (Computer-based Patient Record) Ontology from Free-text Reports for CSI (Computer Semantic Interoperability)

CSI (Computer Semantic Interoperability) is a very important issue in healthcare. Ways for heterogeneous computer systems to “understand” important facts from the clinical process for clinical decision support are now beginning to be addressed. We present here comprehensive contributions to achieve CSI. EHR (Electronic Health Record) systems provide a way to extract reports of the clinicians activity. In order to formalize an automated acquisition from semi-structured, free-form, natural language texts in Portuguese into a Clinical Practice Ontology an important step is to develop the ability of decoding all the nicknames, acronyms and short-hand forms that each clinician tend to write down in their reports. We present the steps to develop clinical vocabularies extracting directly from clinical reports in Portuguese available in the SAM (Sistema de Apoio ao Médico) system. The presented techniques are easily further developed for any other natural language or knowledge representation framework with due adaptations.

A Community Public Health System Design based on HL7 Criterions

The platform integration study on hospital management information system with common interface had the data exchange and sharing on several information platform come true. The external study is to apply the results to bigger score and operating surroundings. The study about Computer-Based Patient Record (CPR) on Health Level Seven (HL7) combing the middleware is to achieve the uniform data and function so that we can exchange and share the medical information. After analysis of the data requirement between the hospital and the medical enterprise, the community medical platform was designed on the HL7 engine to satisfy the data communication and transmission. Combing the middleware the integration platform had the function of query and sharing.

Incidence and prevalence of psoriatic arthritis in Buenos Aires, Argentina: a 6-year health management organization-based study

Studies regarding epidemiology of PsA are lacking in Latin America. We estimated the incidence and prevalence of PsA in a University Hospital-based Health Management Organization in Buenos Aires [Hospital Italiano Medical Care Program (HIMCP)]. for incidence calculation, the population at risk was all adult members of the HIMCP, with continuous affiliation for at least 1 year from January 2000 to January 2006. Each person was followed until he/she voluntarily left the HIMCP, death or finalization of the study (final dates) contributing time at risk since January 2000 or enrolment date (whichever occurred later) to that final date. Case ascertainment: medical records of all patients with the problem psoriasis and/or PsA in the HIMCP problem-oriented computer-based patient record system, or registered in rheumatologists and/or dermatologists databases, were revised. Patients fulfilling CASPAR criteria were included. incidence rate (IR) was calculated with 95% CIs. Cumulative prevalence was estimated on 1 January 2006 (denominator population ==88,112). In the study period, 138,288 persons contributed a total of 558,878 person-years, of whom 35 developed PsA (IR 6.26; 95% CI 4.2, 8.3 cases per 100,000 person-years). There were 12 females: IR 3.64 (95% CI 1.6, 5.7) cases per 100,000 person-years; and 23 males: IR 10.02 (95% CI 5.9, 14.1) cases per 100,000 person-years. On 1 January 2006, 65 prevalent cases were identified: prevalence 74 (95% CI 57, 94) cases per 100,000 members. The incidence and prevalence of PsA in this Latin American country was similar to that reported in other studies from Europe and the USA.

The impact of electronic medical record systems on outpatient workflows: A longitudinal evaluation of its workflow effects

Context The promise of the electronic medical record (EMR) 1 1 The electronic medical record (EMR) is defined as a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems). An ideal EMR's usually encompasses (i) a longitudinal collection of electronic health information for and about person; (ii) electronic access to person- and population-level information by authorized users. lies in its ability to reduce the costs of health care delivery and improve the overall quality of care – a promise that is realized through major changes in workflows within the health care organization. Yet little systematic information exists about the workflow effects of EMRs. Moreover, some of the research to-date points to reduced satisfaction among physicians after implementation of the EMR and increased time, i.e., negative workflow effects. A better understanding of the impact of the EMR on workflows is, hence, vital to understanding what the technology really does offer that is new and unique. Objective (i) To empirically develop a physician centric conceptual model of the workflow effects of EMRs; (ii) To use the model to understand the antecedents to the physicians’ workflow expectation from the new EMR; (iii) To track physicians’ satisfaction overtime, 3 months and 20 months after implementation of the EMR; (iv) To explore the impact of technology learning curves on physicians’ reported satisfaction levels. Design The current research uses the mixed-method technique of concept mapping to empirically develop the conceptual model of an EMR's workflow effects. The model is then used within a controlled study to track physician expectations from a new EMR system as well as their assessments of the EMR's performance 3 months and 20 months after implementation. Setting The research tracks the actual implementation of a new EMR within the outpatient clinics of a large northeastern research hospital. Participants The pre-implementation survey netted 20 physician responses; post-implementation Time 1 survey netted 22 responses, and Time 2 survey netted 26 physician responses. Intervention The implementation of the actual EMR served as the intervention. Since the study was conducted within the same setting and tracked a homogenous group of respondents, the overall study design ensured against extraneous influences on the results. Main outcome measures Outcome measures were derived empirically from the conceptual model. They included 85 items that measured physician perceptions of the EMR's workflow effect on the following eight issues: (1) administration, (2) efficiency in patient processing, (3) basic clinical processes, (4) documentation of patient encounter, (5) economic challenges and reimbursement, (6) technical issues, (7) patient safety and care, and (8) communication and confidentiality. The items were used to track expectations prior to implementation and they served as retrospective measures of satisfaction with the EMR in post-implementation Time 1 and Time 2. Results The findings suggest that physicians conceptualize EMRs as an incremental extension of older computerized provider order entries (CPOEs) rather than as a new innovation. The EMRs major functional advantages are seen to be very similar to, if not the same as, those of CPOEs. Technology learning curves play a statistically significant though minor role in shaping physician perceptions. Conclusions The physicians’ expectations from the EMR are based on their prior beliefs rather than on a rational evaluation of the EMR's fit, functionality, or performance. Their decision regarding the usefulness of the EMR is made very early, within the first few months of use of the EMR. These early perceptions then remain stable and become the lens through which subsequent experience with the EMR is interpreted. The findings suggest a need for communication based interventions aimed at explaining the value, fit, and usefulness of EMRs to physicians early in the pre- and immediate post-EMR implementation stages.

The IR Radlex Project: An Interventional Radiology Lexicon—A Collaborative Project of the Radiological Society of North America and the Society of Interventional Radiology

The IR Radlex Project: An Interventional Radiology Lexicon—A Collaborative Project of the Radiological Society of North America and the Society of Interventional Radiology

A usability evaluation of four commercial dental computer-based patient record systems

The usability of dental computer-based patient record (CPR) systems has not been studied, despite early evidence that poor usability is a problem for dental CPR system users at multiple levels. The authors conducted formal usability tests of four dental CPR systems by using a purposive sample of four groups of five novice users. The authors measured task outcomes (correctly completed, incorrectly completed and incomplete) in each CPR system while the participants performed nine clinical documentation tasks, as well as the number of usability problems identified in each CPR system and their potential relationship to task outcomes. The authors reviewed the software application design aspects responsible for these usability problems. The range for correctly completed tasks was 16 to 64 percent, for incorrectly completed tasks 18 to 38 percent and for incomplete tasks 9 to 47 percent. The authors identified 286 usability problems. The main types were three unsuccessful attempts, negative affect and task incorrectly completed. They also identified six problematic interface and interaction designs that led to usability problems. The four dental CPR systems studied have significant usability problems for novice users, resulting in a steep learning curve and potentially reduced system adoption. The significant number of data entry errors raises concerns about the quality of documentation in clinical practice.

Nursing Care Systems: Enhancing Care Processes in Practice and Management

To summarize aspects of nursing informatics application and introduces challenges that are currently being addressed by nurses around the world. Key contributions in the field are surveyed and put in the perspective of the IMIA Nursing Informatics Strategic Plan. As a discipline, nursing informatics offers real and practical instruments and opportunities to delivery nursing care across settings, units of care and specialties. A variety of patient care systems are managed by nurses who are introduced to this link during their training embracing information networks, communication skills together with an ability to work both in practice and administrative positions in a variety of clinical and community settings. At a time when the tendency is toward a computer-based patient record, nurses must be able to identify what kind of nursing data and information will construct useable and useful nursing knowledge. There are many options for each area of application and the selection must be done carefully, considering the enhancement for organizational, technological and local requirements.

Fifty Years as a Health Information Management Professional: An American Perspective.

Outlines the lessons the author learned throughout her career and end by reflecting on where we are now and on what a lies ahead. To cover the 50-year period (1953-2003), rather than trying to identify all the significant changes that had occurred in the profession, the author reviewed the issues in the American Association of Medical Record Librarians' (AAMRL) professional journal for the years 1953, 1963, 1973, 1983, 1993, and 2003. The author also looked back on what she was doing in those years and what she learned along the way. The introduction of the terms computer-based patient record (CPR) and electronic health record (EHR) are described.