Data Recording System Research Articles

The Effect of Electronic Health Record and Immunization Information System Interoperability on Medical Practice Vaccination Workflow.

Interoperability between electronic health records (EHR) and immunization information systems (IIS) may positively influence data quality, affecting timeliness, completeness, and accuracy of these data. However, the extent to which EHR/IIS interoperability may influence the day-to-day vaccination workflow and related recordkeeping tasks performed at medical practices is unclear. This study aimed to assess how EHR/IIS interoperability may influence the vaccination workflow at medical practices and to identify related impacts on clinical and administrative activities. We identified practices (family medicine, pediatrics, internal medicine, local health departments) from the Michigan Care Improvement Registry (MCIR), the statewide IIS in Michigan, representing each of the three HL7 interoperability levels (non-HL7, unidirectional, bidirectional). We conducted semi-structured interviews to assess how practices interact with the MCIR throughout the vaccination workflow. Transcripts were reviewed and coded to characterize practices' use of EHRs, MCIR, and other related technologies across the vaccination workflow. Practices completed Phase 1 (n = 45) and Phase 2 (n = 42) interviews, representing a range of medical specialties, geographic locations, and sizes. HL7 connectivity expanded among the participating practices; by the conclusion of the study, all practices had initiated at least unidirectional HL7 capability. Providers and staff relied heavily upon both their EHRs and MCIR throughout a wide range of vaccination-related activities. Most practices relied on MCIR as their primary source of vaccination history information, and nearly all practices also reported use of paper forms, documentation, and other summaries throughout the vaccination workflow. Practices employed both their EHRs and IIS throughout the entire vaccination workflow, although the use of each relied heavily on paper-based processes. While benefits of adopting EHR/IIS interoperability were reported by practices, this may require staff to learn and implement new workflow processes that can be time consuming and may introduce new challenges.

Rancang Bangun Sistem Informasi Pencatatan dan Pengelolaan Data Pekerjaan Karyawan di PT Aplic Digital Teknologi

The design and development of an information system for recording and managing employee work data aim to simplify the process of tracking and monitoring employee tasks, including when tasks are assigned and when they are expected to be completed. This system is designed to replace manual administrative processes, enabling work-related information to be accessed more quickly and accurately. The method used is System Development Life Cycle (SDLC) with system development using a waterfall method approach which involves the stages of needs analysis, design, design, and implementation. With this system, management can regularly monitor the progress of employee tasks and evaluate the efficiency of task completion. Additionally, the system records work history, which can be used for reporting and further analysis. The implementation results show that the system improves the accuracy of work data recording and supports more effective decision-making.

Using data from routine health information systems as a public good in Trinidad and Tobago.

This study aimed to explore the use of data from routine health information systems (RHIS) as a public good in Trinidad and Tobago, the challenges faced in doing this and opportunities for strengthening the health information system. For this descriptive qualitative study, purposive sampling was utilized to recruit 19 people who used or produced RHIS data. Online interviews were conducted via Zoom, and all interviews were recorded and transcribed. Pseudonyms were used to protect participants' identity. Transcripts were cleaned and analyzed using Dedoose (v. 9.0.17; Dedoose, Los Angeles, CA, USA). There was significant underutilization of RHIS data as a public good, primarily due to challenges related to data access and quality. Access to the data was stymied by burdensome bureaucratic processes, paper-based recording and storage systems, and ownership and security concerns. Data quality was adversely affected by a lack of standardized data collection forms and processes, staff training, data completeness, and also by technological and infrastructural constraints. Key opportunities for increasing the use of Trinidad and Tobago's RHIS data would include addressing the need for a national electronic health information system, ensuring adequate training for staff involved in data management, and developing a comprehensive monitoring and evaluation plan. Data quality and access must be improved to enable greater use of RHIS data as a public good in Trinidad and Tobago. The planned change from a paper-based to a national electronic data recording and storage system must be expedited, and it should be accompanied by the standardization of processes, and investments in adequate staffing and timely training. Appropriate technological and infrastructural support, as well as an improved data governance system, are also required.

Implementation of COBIT 2019 with Domain DSS01, DSS03, and MEA01 for Audit of Customer Water Usage Recording Information System at HIPPAM Mandiri Arjowinangun

Currently, HMA faces challenges in optimizing the recording system, because the meter recording process is still done manually. This manual process hampers operational efficiency and data accuracy which impacts the quality of service to customers. Therefore, it is necessary to evaluate the existing information system to measure whether the application of information technology is in accordance with the goals and expectations of the organization. This study aims to analyze the application of information technology in HMA using the COBIT 2019 framework, specifically in the domains DSS01 (Manage Operations), DSS03 (Manage Problems), and MEA01 (Monitor, Evaluate, and Assess Performance). Through capability analysis in these three domains, this study identifies gaps in the existing system and provides recommendations for improvements to improve the efficiency and accuracy of the customer water usage recording system. The results of the study indicate that HMA's capability level is still below the desired target, so it is important to make improvements by implementing more integrated digital solutions and improving continuous monitoring and evaluation of system performance.

Electronic Medical Record Information System to Support Clinical Management of Web-Based Medical Report Resumes

Medical records are important documents that record patient information, including examinations, treatments, actions, and services. Article 46 paragraph (1) of the Medical Practice Law defines medical records as files containing patient identity, examination results, treatments, actions, and other services. Regulation of the Minister of Health No. 21 of 2020 concerning the Integration of Health Information Systems, in the Ministry of Health's Strategic Plan 2020-2024, emphasizes the importance of a fast, accurate, integrated, and electronic-based health information system. This study aims to develop an electronic medical record information system for creating web-based medical resumes, using Visual Studio Code, PHP, MySQL, and Laravel. The development method used is agile. The results of the study show that the application of the agile method in developing web-based medical resumes increases effectiveness and efficiency. The problem identified is manual medical resume writing, which is often illegible, making it less efficient. To overcome this, an electronic medical resume design was developed as part of an electronic medical record system, which allows for faster, timelier, and clearer medical resume creation. This medical resume management system is expected to increase efficiency and readability

Sistem Informasi Rekam Medis Klinik Kasih Murni Berbasis web

In the midst of the rapid advancement of information and communication technology, fast and accurate information is increasingly becoming the main need for decision makers. In other words, information is a basic requirement required by every management to make decisions. Even a hospital as an institution that stores a lot of data also requires correct and accurate data processing that can be presented in such a way in the form of a report. Presentation of reports in the form of information must be in accordance with the value of the use and function of each part. One of them is a web-based medical record information system. In this study, the design and analysis techniques in the manufacture used the Waterfall method. This system has been tested using black box testing to get the expected results and the system is feasible to use. Based on the results of the description and discussion of the final project report, a Medical Record Information System has been successfully built in the Kasih Murni clinic for monitoring health in Website-Based Children using the waterfall method and the code igniter framework with the PHP programming language. The system is expected to be able to assist in processing medical records in clinics and hospitals where as long as the recording of medical record data is still done manually.

Evaluate the Differential Effectiveness of the Case Management and Primary Nursing Models in the Implementation of Discharge Planning.

This study aims to compare the effectiveness of the case management model and the primary nursing care model by focusing on hospital stay length, readmission, follow-up resource utilisation and survival. To improve patient continuity of care, a discharge planning team has been established at the hospital to implement the service concept of long-term medical care. The team works with a multidisciplinary medical team to provide case management, which ensures high-quality patient care. Retrospective case-control study. This study collected data from the medical record information system database and the Ministry of Health and Welfare's care service management information system to explore medical and follow-up care utilisation of patients discharged between 2017 and 2018. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, with the checklist used to ensure transparent and complete reporting of the methodology and results. To ensure comparability between the case management model group and the primary nursing model group, propensity score matching was used. After matching, 660 individuals from the case management model group and 2876 individuals from the primary nursing model group were selected for further analysis. In this study, patients were primarily involved in the research as participants, providing data through their medical records for analysis. However, no direct involvement from the public or patients was used in the planning or design stages of the research. The study found that factors such as activities of daily living (ADL) score ≤ 60 points, catheterisation, poor chronic disease control and inadequate primary caregiver capacity can lead to longer hospitalisations. Males and patients with catheters have a higher risk of readmission within 30 days, and men, those aged ≥ 75 years, those with ADL score ≤ 60, catheterisation, pressure sores or unclean wounds, financial problems, insufficient primary caregiver capacity and those readmitted within 14 days after discharge had significantly increased mortality after discharge. Although the case management model group had higher hospitalisation days, they had lower readmission rates and higher survival rates than the primary nursing model group. Early consultation with the case manager for discharge planning can help patients to continue to receive care and utilise relevant resources after returning home. Identifying and addressing patient-specific factors can significantly improve patient outcomes by reducing hospitalizations and readmissions, and lowering mortality rates. The case management model is more effective than the primary nursing care model in reducing readmission rates and increasing survival rates. Early consultation with case managers for discharge planning is crucial to ensuring patient care continuity and resource utilization.

Development and deployment of an Emergency Department-Radiology Dashboard to improve communication and transparency of radiology imaging and report status

The status of radiology examinations affects the flow of patients through the emergency department (ED). Yet this information is not readily available to ED physicians, nurses, and staff members (collectively referred to as ED staff members) or patients. The aim of this study was to improve ED workflow by providing real-time information about the status of radiology reports to ED staff members. A dashboard displaying real-time information on the status of pending radiology examinations as extracted from the electronic medical record and radiology information system was developed for display in the ED. An algorithm based on historical trends was developed for predicting expected turnaround times (TATs). Focus groups, surveys, and dashboard use data were used to gather feedback and understand utility. The ED radiology dashboard was successfully deployed to four EDs within the health system. The dashboard received an average of 9,397 unique views per week the first year and 802 views per week in the following 2 years after deployment. Most examinations had TATs better than the estimated time, and fewer than 1% had TATs greater than 2 hours from the estimated time. No differences were found between pre- and postsurvey opinion results. A web-based dashboard that displays radiologic imaging study status is a low-cost, high-yield method to improve communication between radiology and ED staff members.

Improvement of management information system to facilitate recording and reporting for Integrated Health Service cadres

In the Penatih Dangin Puri Village area, the Integrated Health Service (posyandu) activities data recording by cadres is still carried out manually using forms which are then recorded again in the SIP book. This data recording system still has many shortcomings, so this community service aims to provide an integrated recording system and provide training to facilitate posyandu data recording and reporting activities. Carried out in the form of training and implementation related to data entry and making reports for toddler posyandu based on the posyandu Information System (SIPOS). SIPOS training activities with Human Development Cadre partners in Penatih Dangin Puri Village began on September 27 2023. Attended by 65 cadres from 13 Banjars. Latter evaluation has been carried out and shows that the average accuracy of using SIPOS after training is 80 percent and increased to 94 percent after implementation. With the level of accuracy in filling out the data entry and report extract features, most of them have a percentage of 80 percent, but there is an accuracy level of 80 percent, namely in the date of birth entry feature (55 percent) and entering the date of visit (51 percent). Community service activities succeeded in improving cadres' skills in recording and reporting information system-based posyandu data.

Anaphylaxis in a country where Asia and Europe meet: Evaluation according to World Allergy Organization (WAO) and European Academy of Allergy and Clinical Immunology (EAACI) diagnostic criteria

Anaphylaxis in a country where Asia and Europe meet: Evaluation according to World Allergy Organization (WAO) and European Academy of Allergy and Clinical Immunology (EAACI) diagnostic criteria

CLINICOHISTOPATHOLOGICAL STUDY OF TESTICULAR TUMOURS IN DR. HASAN SADIKIN GENERAL HOSPITAL BANDUNG

Objective: The purpose of this research was to describe the clinical and histopathological characteristics of testicular tumours at Hasan Sadikin General Hospital (RSHS) between 2017-2021. Material & Methods: This research was a cross-sectional descriptive study examining the clinical and histopathological profiles of testicular tumours. The secondary data sources included medical records from the Department of Urology, Anatomic Pathology, Medical Records, and Hospital Information System (SIRS). The collected data covered age, ethnicity, clinical symptoms, site, stage, annual prevalence rate, and analyzed using Microsoft Excel. Results: There were 42 patients who had primary testicular tumour. The highest prevalence of testicular tumours at RSHS was in 2019 consist of 12(29%) patients and the lowest in 2020 were 6(14%) patients. Most patients were >35 years old amounting 19(45%) patients, Sundanese ethnicity were 29(69%) patients, and testicular enlargement revealed in 27(64%) patients. Majority patients were in stage 0/IB 36(86%) patients and occurred in unilateral testis which 34(80%) patients, with 3(7%) patients metastasized. The most common histopathological type was seminoma 18(43%) cases followed by prepubertal-type yolk sac tumour 9(21%) patients. Seminomas, and the fibroma-thecoma group were mostly in patients over 35 years old, while prepubertal-type yolk sac tumour was more commonly in children under 15 years old. Conclusion: Prevalence of testicular tumours increased from 2017 to 2019, then started to decrease in 2020. Histopathologically, seminoma was the most common type. These tumours were most commonly found in older individuals (>35 YO) and unilateral, diagnosed in stage 0/IB, and were mostly presented with enlargement of testis. Keywords: Testicular tumours, clinical features, histopathology

What’s behind thoracic surgery explosion in young patients under the age of 40 in Wuhan after COVID-19 outbreak?

The COVID-19 pandemic was associated with a dramatic increase of chest CT scanning in Wuhan. This was partly a COVID effect: some private and public employers required employees to have CT examinations to confirm they were healthy before going back to work. But it also likely reflects the growing enthusiasm for low-dose computed tomography (LDCT) screening. This investigation examines the resulting impact in the under 40 population. The relevant de-identified information of the patients under age 40 who had also received thoracic surgery from 2018 to 2022 was analyzed using the medical record information system of Tongji Hospital in Wuhan. The volume of thoracic surgeries increased continuously in young patients under the age of 40, from 219 in 2018 to 732 in 2022. The number of surgeries for pulmonary nodules or masses in this group increased over 6-fold, from 91 to 576. The number of surgeries leading to a diagnosis of adenocarcinoma of the lung increased more than 15-fold, from 26 to 415. The median adenocarcinoma size fell in half (from 15mm to 7mm) and the most common stage changed from Stage I invasive (46% of adenocarcinomas in 2018) to microinvasive (60% of adenocarcinomas in 2022). 70% of lung adenocarcinomas were found in females. There had been an explosion of thoracic surgery for adenocarcinomas among the under-40 population in Wuhan. The decrease in tumor size and the increase in microinvasive and in situ lesions in this young age group suggest considerable overdiagnosis. We should be vigilant about the risk of overdiagnosis and overtreatment especially in young women.

PEMANFAATAN UML (UNIFIED MODELING LANGUAGE) DALAM PERANCANGAN SISTEM REKAM MEDIS SEDERHANA PADA KEGIATAN POSBINDU PTM ARSO III

The Integrated Non-Communicable Diseases Development Post (Posbindu NCD) is a form of health empowerment and public knowledge about non-communicable diseases that have a greater risk. In this Posbindu NCD, of course there are activities and steps that have been determined. The purpose of this study was to determine the concept of Posbindu NCD itself and the use of UML (Unified Modelling Language) to develop a simple medical record information system. The use of UML is done because in the characteristics of UML there is the possibility of identification of any objects that affect the system. The research method used is literature review and interviews with cadres on duty. Meanwhile, the journal criteria used are in the 2011- 2020 range. The results of this study indicate that Posbindu NCD is very useful for early detection of non-communicable diseases and the use of UML to develop a simple medical record information system is very efficient.)

Electronic data capture in resource-limited settings using the lightweight clinical data acquisition and recording system

Our prototype system designed for clinical data acquisition and recording of studies is a novel electronic data capture (EDC) software for simple and lightweight data capture in clinical research. Existing software tools are either costly or suffer from very limited features. To overcome these shortcomings, we designed an EDC software together with a mobile client. We aimed at making it easy to set-up, modifiable, scalable and thereby facilitating research. We wrote the software in R using a modular approach and implemented existing data standards along with a meta data driven interface and database structure. The prototype is an adaptable open-source software, which can be installed locally or in the cloud without advanced IT-knowledge. A mobile web interface and progressive web app for mobile use and desktop computers is added. We show the software’s capability, by demonstrating four clinical studies with over 1600 participants and 679 variables per participant. We delineate a simple deployment approach for a server-installation and indicate further use-cases. The software is available under the MIT open-source license. Conclusively the software is versatile, easily deployable, highly modifiable, and extremely scalable for clinical studies. As an open-source R-software it is accessible, open to community-driven development and improvement in the future.

Medical Record Information System Testing Using User Acceptance Testing to Determine System Quality

Medical Record Information System Testing Using User Acceptance Testing to Determine System Quality

Genomic surveillance and vaccine response to the dominant SARS-CoV-2 XBB lineage in Rio Grande do Sul

The COVID-19 pandemic has been marked by novel viral variants, posing challenges to global public health. Recombination, a viral evolution mechanism, is implicated in SARS-CoV-2's ongoing evolution. The XBB recombinant lineage, known for evading antibody-mediated immunity, exhibits higher transmissibility without increased disease severity. We investigated the prevalence and genomic features of XBB in SARS-CoV-2-positive cases in Rio Grande do Sul (RS), Brazil. We sequenced 357 samples from epidemiological weeks (EW) 47/2022 to 17/2023, and included 389 publicly available sequences. Clinical and epidemiological data were obtained from DATASUS, e-SUS, and SIVEP GRIPE (data recording systems of the Brazilian Ministry of Health). Of these, 143 were classified as XBB and 586 were other Omicron lineages. In March 2023 (EW 10), XBB became dominant, accounting for 83.3% of cases. 97.7% of XBB-infected patients successfully recovered from the infection, with a low mortality rate (2.3%). Even after receiving three vaccine doses and having been previously infected, 59.5% of the patients experienced reinfection with XBB. However, for 54% of the individuals, the interval between their XBB infection and the last vaccine dose exceeded one year, potentially leading to a decline in antibody levels. In addition, we identified 90 mutations in RS circulating XBB, spread throughout the genome, notably in the Spike protein region associated with immune resistance. This study provides insights into the dynamics and impact of a recombinant variant becoming predominant for the first time in the state. Continued surveillance of SARS-CoV-2 genomic evolution is crucial for effective public health management.

Analisis Kesiapan Implementasi Rekam Medis Elektronik Rawat Jalan di Rumah Sakit X

Changing the medical record information system from manual to electronic will make it easier to record information about patients in a practical and fast way. This change is related to the Regulation of the Minister of Health of the Republic of Indonesia, namely that all health facilities are expected to have implemented electronic medical records in accordance with the provisions no later than December 31, 2023. In this case, it is necessary to know the level of readiness of hospitals in implementing outpatient electronic medical records. The purpose of this study was to analyze to determine the readiness of implementing outpatient electronic medical records at Hospital X using the Doctor's Office Quality – Information Technology (DOQ-IT) method. The type of research used is descriptive quantitative. The research instrument is a questionnaire. Readiness analysis using the EHR Readiness Starter Assessment from DOQ-IT. The level of readiness for the implementation of outpatient electronic medical records at Tk. III Dr. R. Soeharsono Banjarmasin is very well prepared. This value is included in the very ready score range. While the level of readiness for implementation in the variable, namely, organizational work culture of 42.14 is in the very ready score range, 34.72 leadership governance is in the very ready score range, human resources is 21.19 in the very ready score range, and IT infrastructure of 15.69 is in the fairly ready range of scores.

Akurasi dan Ketepatan Pengkodean Diagnosis pada Kasus Obstetric di RST Dr. Asmir DKT Salatiga

Accurate and precise diagnosis coding in obstetric cases at Dr. Asmir DKT Hospital, Salatiga, is crucial for effective medical record management. This study utilized an analytical quantitative approach with a cross-sectional method to explore the relationship between the accuracy and precision of diagnosis coding. The sample comprised 100 obstetric cases selected from inpatients during the first quarter (January – March 2024). Data analysis revealed that 68% of the 72 analyzed cases had accurate diagnosis coding, while 32% were inaccurate. Similarly, 71% of the cases were coded precisely, with 29% coded imprecisely. Chi-Square analysis indicated a significant relationship between accuracy and precision of diagnosis coding (p = 0.002). Factors influencing inaccuracies and imprecisions in coding included legibility of physician notes in medical records, inadequate understanding of the coding system (ICD-10), and completeness of medical documentation. To enhance coding quality, regular training for healthcare staff is recommended, alongside strengthening internal audit systems and developing more efficient medical record information systems.

Estimation of the genetic parameters of sheep growth traits based on machine vision acquisition

In the realm of animal phenotyping, manual measurements are frequently utilised. While machine-generated data show potential for enhancing high-throughput breeding, additional research and validation are imperative before incorporating them into genetic evaluation processes. This research presents a method for managing meat sheep and collecting data, utilising the Sheep Data Recorder system for data input and the Sheep Body Size Collector system for image capture. The study aimed to investigate the genetic parameter changes of growth traits in Ujumqin sheep by comparing machine-generated measurements with manual measurements. The dataset consisted of 552 data points from the offspring of 75 breeding rams and 399 breeding ewes. Six distinct random regression models were assessed to pinpoint the most suitable model for estimating genetic parameters linked to growth traits. These models were distinguished based on the inclusion or exclusion of maternal genetic effects, maternal permanent environmental effects, and covariance between maternal and direct genetic effects. Fixed factors such as individual age, individual sex, and ewe age were taken into account in the analysis. The genetic parameters for the yearling growth traits of Ujumqin sheep were calculated using ASReml software. The Akaike information criterion, the Bayesian information criterion, and fivefold cross-validation were employed to identify the optimal model. Research findings indicate that the most accurate models for manually measured data revealed heritability estimates of 0.12±0.15 for BW, 0.05±0.07 for body slanting length, 0.03±0.07 for withers height, 0.15±0.12 for hip height, 0.11±0.11 for chest depth, 0.13±0.13 for shoulder width, and 0.53±0.15 for chest circumference. The optimal models for machine-predicted data showed heritability estimates of 0.1±0.09 for body slanting length, 0.14±0.12 for withers height, 0.55±0.15 for hip height, 0.34±0.15 for chest depth, 0.26±0.15 for shoulder width, and 0.47±0.16 for chest circumference. In manually measured data, genetic correlations ranged from 0.35 to 0.99, while phenotypic correlations ranged from 0.07 to 0.90. In machine data, genetic correlations ranged from -0.05 to 0.99, while phenotypic correlations ranged from 0.03 to 0.84. The results suggest that machine-based estimations may lead to an overestimation of heritability, but this discrepancy does not impact the selection of breeding models.

WEBSITE DESIGN INFORMATION SYSTEM OF RECORDING OFFENS AND PUNISHMENT STUDENTS SMK MUHAMMADIYAH 8 SILIRAGUNG USE WATERFALL DEVELOPMENT METHOD

Educational institutions as learning centers are prepared so they keep up through developments, especially regarding the use of information systems which are expected to facilitate the completion of work effectively and in an efficient time so institutions can improve their quality achievements. In this case, SMK Muhammadiyah 8 Siliragung experienced issues in the counselling division regarding recording violations and sanctions which required plenty of time to process and search for the required documents manually. To overcome issues, an information system for recording, as well as storing the history of violations carried out in a computerized manner efficiently to search for history data. This system development uses waterfall development methodology with a MySQL storage database and WEB-based PHP programming language. This research succeeded in identifying the needs through data collection methods, analysis of needs planning and observation meanwhile the system is equipped with a login and logout, a student data, a record, an administration letter, as well as a problematic student data report feature with a violation filter. This information system have been to overcome the issues.