Free-text Elements Research Articles

Implementation and Analysis of an Institution-Wide EHR-Integrated Handoff Note.

EHR-Integrated Handoff Notes are becoming increasingly prevalent, especially among inpatient clinical service teams composed of physicians in training (resident physicians). We describe the implementation of such a tool at our institution, and then describe the usage of the tool, as well as changes made to its content, structure, and format, years after original implementation. We also describe frequency and temporal distribution of updates made to free text elements of the Handoff Note. At the initial implementation there were three versions available; medical/surgical, pediatric, and ICU. Years after implementation, 57% of clinical service teams continue to utilize the note, including all medical, pediatric, behavioral health, obstetrics/gynecology, and neurology services, as well as most surgical services, that serve as "primary" teams. Several interesting changes were noted to the content and structure of the Handoff Note, namely that more complicated versions were abandoned in favor of simpler versions. The Patient Summary and To Do free text boxes are updated an average of 1.0 and 1.6 times per day. Around 60% of updates to both free text boxes occur between 12 pm - 5:59 pm, likely in preparation for the daytime-nightime team handoff.

Saving Time for Patient Care by Optimizing Physician Note Templates: A Pilot Study.

Background: At times, electronic medical records (EMRs) have proven to be less than optimal, causing longer hours behind computers, shorter time with patients, suboptimal patient safety, provider dissatisfaction, and physician burnout. These concerning healthcare issues can be positively affected by optimizing EMR usability, which in turn would lead to substantial benefits to healthcare professionals such as increased healthcare professional productivity, efficiency, quality, and accuracy. Documentation issues, such as non-standardization of physician note templates and tedious, time-consuming notes in our mother-baby unit (MBU), were discussed during meetings with stakeholders in the MBU and our hospital's EMR analysts.Objective: The objective of this study was to assess physician note optimization on saving time for patient care and improving provider satisfaction.Methods: This quality improvement pilot investigation was conducted in our MBU where four note templates were optimized: History and Physical (H and P), Progress Note (PN), Discharge Summary (DCS), and Hand-Off List (HOL). Free text elements documented elsewhere in the EMR (e.g., delivery information, maternal data, lab result, etc.) were identified and replaced with dynamic links that automatically populate the note with these data. Discrete data pick lists replaced necessary elements that were previously free texts. The new note templates were given new names for ease of accessibility. Ten randomly chosen pediatric residents completed both the old and new note templates for the same control newborn encounter during a period of one year. Time spent and number of actions taken (clicks, keystrokes, transitions, and mouse-keyboard switches) to complete these notes were recorded. Surveys were sent to MBU providers regarding overall satisfaction with the new note templates.Results: The ten residents' average time saved was 23 min per infant. Reflecting this saved time on the number of infants admitted to our MBU between January 2016 and September, 2019 which was 9373 infants; resulted in 2.6 hours saved per day, knowing that every infant averages two days length of stay. The new note templates required 69 fewer actions taken than the old ones (H and P: 11, PN: 8, DCS: 18, HOL: 32). The provider surveys were consistent with improved provider satisfaction.Conclusion: Optimizing physician notes saved time for patient care and improved physician satisfaction.

Can Prehospital Data Improve Early Identification of Sepsis in Emergency Department? An Integrative Review of Machine Learning Approaches.

Sepsis is associated with high mortality, especially during the novel coronavirus disease 2019 (COVID-19) pandemic. Along with high monetary health care costs for sepsis treatment, there is a lasting impact on lives of sepsis survivors and their caregivers. Early identification is necessary to reduce the negative impact of sepsis and to improve patient outcomes. Prehospital data are among the earliest information collected by health care systems. Using these untapped sources of data in machine learning (ML)-based approaches can identify patients with sepsis earlier in emergency department (ED). This integrative literature review aims to discuss the importance of utilizing prehospital data elements in ED, summarize their current use in developing ML-based prediction models, and specifically identify those data elements that can potentially contribute to early identification of sepsis in ED when used in ML-based approaches. Literature search strategy includes following two separate searches: (1) use of prehospital data in ML models in ED; and (2) ML models that are developed specifically to predict/detect sepsis in ED. In total, 24 articles are used in this review. A summary of prehospital data used to identify time-sensitive conditions earlier in ED is provided. Literature related to use of ML models for early identification of sepsis in ED is limited and no studies were found related to ML models using prehospital data in prediction/early identification of sepsis in ED. Among those using ED data, ML models outperform traditional statistical models. In addition, the use of the free-text elements and natural language processing (NLP) methods could result in better prediction of sepsis in ED. This study reviews the use of prehospital data in early decision-making in ED and suggests that researchers utilize such data elements for prediction/early identification of sepsis in ML-based approaches.

Obstacles to the reuse of study metadata in ClinicalTrials.gov

Metadata that are structured using principled schemas and that use terms from ontologies are essential to making biomedical data findable and reusable for downstream analyses. The largest source of metadata that describes the experimental protocol, funding, and scientific leadership of clinical studies is ClinicalTrials.gov. We evaluated whether values in 302,091 trial records adhere to expected data types and use terms from biomedical ontologies, whether records contain fields required by government regulations, and whether structured elements could replace free-text elements. Contact information, outcome measures, and study design are frequently missing or underspecified. Important fields for search, such as condition and intervention, are not restricted to ontologies, and almost half of the conditions are not denoted by MeSH terms, as recommended. Eligibility criteria are stored as semi-structured free text. Enforcing the presence of all required elements, requiring values for certain fields to be drawn from ontologies, and creating a structured eligibility criteria element would improve the reusability of data from ClinicalTrials.gov in systematic reviews, metanalyses, and matching of eligible patients to trials.

Jurisdictional Etiquette Workgroup: An offshoot of a Syndromic Surveillance Consortium

Objective● To demonstrate the importance of a cross-jurisdictional etiquette workgroup in the Texas Southeast region that leverages on the Syndromic Surveillance Consortium● To promote data sharing and communicate the findings of disease to assist rapid investigation and data sharingKey words:ESSENCE (Electronic Surveillance System for Early notification of Community-based Epidemics)IntroductionSyndromic data is shifting the way surveillance has been done traditionally. Most recently, surveillance has gone beyond city limits and county boundary lines. In southeast Texas, a regional consortium of public health agencies and stakeholders in the 13-County area governs the local ESSENCE system. The Houston Health Department, (HHD) is responsible for deploying ESSENCE to the entire region.To effectively monitor the health of the region’s population, a need arose to establish clear guidelines for disease investigation and data sharing triggered by syndromic surveillance across the area. Since Houston’s instance of ESSENCE serves all 13 counties, the consortium instituted a cross- jurisdictional etiquette group. The purpose of the group is to determine the standard protocol for responding to ESSENCE alerts and best practices for data sharing and use among consortium members.MethodsTo achieve these goals, it was determined that a smaller group of stakeholders besides governing officials is needed to provide guidance for regional data sharing and use. The etiquette group was established in the first quarter of 2018 and it included four consortium representatives from the 6/5 south region of Texas. Their first meeting tackled issues relating to data sharing.ResultsThe following products emerged from the activities of the etiquette group within 3 months of its existence:● Publication/presentation guidance/policy to avoid duplication of efforts and misrepresentation of jurisdiction.● Procedure for alert responses●. Instructions for within-systems management of alerts;●. Instructions for events/times of interest (e.g., political convention, Olympics);● Instructions of syndromes of interest/syndrome-specific policies;● Instructions for changing the syndrome definition;● Notification procedures for identification of a single case of reportable disease/important free text element within data.ConclusionsCross jurisdictional workgroups can influence rapid investigations of disease, protect patient health information and promote privacy and data security and confidentiality by establishing set rules/guidelines for data exchange. All 13-counties in the region rely on these guidelines as a standard for responsibly accessing, using and sharing data in the Texas Southeast ESSENCE system.Lessons Learned:● As the etiquette group continues to evolve, there is need for more resources to help foster data use and sharing among jurisdictional partners.● Partner engagement is limited due to ongoing process of configuring the new system ESSENCE.● Since disease has no boundaries, allocation of jurisdictional responsibilities for responding to alerts should be operationalized● Continuous training is essential to ensure all system users adhere to the protocols in place for meaningful data use and data sharing

Syndrome Development to Assess IDU, HIV, and Homelessness in MA Emergency Departments

Syndrome Development to Assess IDU, HIV, and Homelessness in MA Emergency Departments

Review of never and serious events related to dentistry 2005-2014.

Aims To review never and serious events related to dentistry between 2005-2014 in England.Methods Data from the National Reporting and Learning System (NRLS), with agreed data protection and intelligence governance, was used - snapshot view using the timeframe January 2005 to May 2014. The Strategic Executive Information System (STEIS) database was reported separately for 2012-2013 and 2013-2014. The free text elements from the database were analysed thematically and reclassified according to the nature of the patient safety incident (PSI).Results From the NRLS dataset, 32,263 patient safety events were reported between 1 January 2005 and 30 May 2014. Never events (NEs) from STEIS files were all wrong site extractions (WSS), reported separately for 2012-2013 and 2013-2014. The total number was 43.36 of the 43 PSIs were WSS involving: multiple extractions and bimodal age distribution (very young or over 60 years). Forty-seven percent of never events resulted in no harm, 20% low harm, 7% moderate harm, less than 1% severe harm and 23 deaths over this period (five of which were not related to dentistry). Serious harm and death risk factors included: care in an acute trust ward, peri oncological, reconstructive surgery (OMFS), patient age over 67 years with concurrent medical complexity (Ischaemic heart disease). Sixty percent of PSIs occurred in OS/OMFS in acute trust inpatients and 20% in primary care. From STEIS 2012-2013, 21 WSS were reported of which 50% occurred in oral surgery (OS) or oral and maxillofacial surgery (OMFS). The reported sites were 45% in operating theatre and 42% in dental surgery.Conclusion Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely carried out. Improved awareness and training, simplifying the reporting systems improved non-punitive support by regulators would allow the improvement of patient safety in dental practise.

Optimized Computerized Order Entry can Reduce Errors in Electronic Prescriptions and Associated Pharmacy Calls to Clarify (CTC).

After implementation of a system-wide EMR within our university system, e-prescribing is now commonplace. The authors conducted a study to assess whether optimization of computerized provider order entry (CPOE) can reduce errors in these electronically transmitted prescriptions and would require less frequent interventions from pharmacists, in particular the need for them to "call to clarify" (CTC) details of particular prescriptions. Secondary analysis based on cost assumptions was preformed to presume cost differences before and after optimization changes. In order to generate complete, error-free prescriptions, optimization changes were implemented in the form of in line validation messages. These messages were generated if (1) an order did not specify a provider or pharmacy; (2) the DEA requirements were not met; (3) character limits were exceeded in patient sig or demographics or (4) administration instructions had breaks or had both discrete and free text elements. Retrospectively, prescriptions were randomly selected from a nine month period before and after implementing changes. These prescriptions were analyzed by a pharmacist and a nurse to identify types of errors that would require a CTC to a prescribing provider. Errors were compared statistically to determine effectiveness of changes pre and post optimization. A total of 602 prescriptions were analyzed; 301 before changes and 301 after changes. Of these prescriptions, 20.27% had errors before changes and 12.96% had errors after changes. The decline in the error rate was considered statistically significant for p<0.05. The cost savings were estimated at $76 per 100 prescriptions for pharmacist and physician time-cost estimates combined. Implementing optimization changes to the CPOE resulted in a reduction in error rate requiring pharmacist CTC. This study identifies effective optimization changes for electronic prescribing that can reduce prescribing errors and may result in cost saving.

Patient safety in dentistry – state of play as revealed by a national database of errors

Modern dentistry has become increasingly invasive and sophisticated. Consequently the risk to the patient has increased. The aim of this study is to investigate the types of patient safety incidents (PSIs) that occur in dentistry and the accuracy of the National Patient Safety Agency (NPSA) database in identifying those attributed to dentistry. The database was analysed for all incidents of iatrogenic harm in the speciality of dentistry. A snapshot view using the timeframe January to December 2009 was used. The free text elements from the database were analysed thematically and reclassified according to the nature of the PSI. Descriptive statistics were provided. Two thousand and twelve incident reports were analysed and organised into ten categories. The commonest was due to clerical errors - 36%. Five areas of PSI were further analysed: injury (10%), medical emergency (6%), inhalation/ingestion (4%), adverse reaction (4%) and wrong site extraction (2%). There is generally low reporting of PSIs within the dental specialities. This may be attributed to the voluntary nature of reporting and the reluctance of dental practitioners to disclose incidences for fear of loss of earnings. A significant amount of iatrogenic harm occurs not during treatment but through controllable pre- and post-procedural checks. Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely used. The use of a dental specific reporting system would aid in minimising iatrogenic harm and adhere to the Care Quality Commission (CQC) compliance monitoring system on essential standards of quality and safety in dental practices.

Summary of: Patient safety in dentistry – state of play as revealed by a national database of errors

Modern dentistry has become increasingly invasive and sophisticated. Consequently the risk to the patient has increased. The aim of this study is to investigate the types of patient safety incidents (PSIs) that occur in dentistry and the accuracy of the National Patient Safety Agency (NPSA) database in identifying those attributed to dentistry. The database was analysed for all incidents of iatrogenic harm in the speciality of dentistry. A snapshot view using the timeframe January to December 2009 was used. The free text elements from the database were analysed thematically and reclassified according to the nature of the PSI. Descriptive statistics were provided. Two thousand and twelve incident reports were analysed and organised into ten categories. The commonest was due to clerical errors - 36%. Five areas of PSI were further analysed: injury (10%), medical emergency (6%), inhalation/ingestion (4%), adverse reaction (4%) and wrong site extraction (2%). There is generally low reporting of PSIs within the dental specialities. This may be attributed to the voluntary nature of reporting and the reluctance of dental practitioners to disclose incidences for fear of loss of earnings. A significant amount of iatrogenic harm occurs not during treatment but through controllable pre- and post-procedural checks. Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely used. The use of a dental specific reporting system would aid in minimising iatrogenic harm and adhere to the Care Quality Commission (CQC) compliance monitoring system on essential standards of quality and safety in dental practices.

Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors.

BackgroundOrthopaedic surgery is a high-risk specialty in which errors will undoubtedly occur. Patient safety incidents can yield valuable information to generate solutions and prevent future cases of avoidable harm. The aim of this study was to understand the causative factors leading to all unnecessary deaths in orthopaedics and trauma surgery reported to the National Patient Safety Agency (NPSA) over a four-year period (2005–2009), using a qualitative approach.MethodsReports made to the NPSA are categorised and stored in the database as free-text data. A search was undertaken to identify the cases of all-cause mortality in orthopaedic and trauma surgery, and the free-text elements were used for thematic analysis. Descriptive statistics were calculated based on the incidents reported. This included presenting the number of times categories of incidents had the same or similar response. Superordinate and subordinate categories were created.ResultsA total of 257 incident reports were analysed. Four main thematic categories emerged. These were: (1) stages of the surgical journey – 118/191 (62%) of deaths occurred in the post-operative phase; (2) causes of patient deaths – 32% were related to severe infections; (3) reported quality of medical interventions – 65% of patients experienced minimal or delayed treatment; (4) skills of healthcare professionals – 44% of deaths had a failure in non-technical skills.ConclusionsMost complications in orthopaedic surgery can be dealt with adequately, provided they are anticipated and that risk-reduction strategies are instituted. Surgeons take pride in the precision of operative techniques; perhaps it is time to enshrine the multimodal tools available to ensure safer patient care.

Early Psychosocial Intervention Following Operational Deployment: Analysis of a Free Text Questionnaire Response

United Kingdom Armed Forces personnel currently undertake arduous operational tours that can make homecoming psychologically challenging. To assist them in this transition, they undergo a process of "decompression" before returning to their base unit. This article reports their subjective impression of the process. Personnel completed a brief survey at the end of the decompression process conducted in Cyprus in 2008 and this study reports the analysis of the free text element of the questionnaire. 6,734 comments were available for analysis from a total of 11,304 questionnaires. Although responses were largely positive, significant numbers indicated that decompression could be improved by allowing personnel more choice, improving air transport out of theatre, and greater flexibility in harmonizing decompression activities with the operational role and military characteristics of decompressing units. Although decompression is generally viewed positively by participants, elements of the process could be further developed to improve acceptability.

Interprétation vague des contraintes structurelles pour la RI dans des corpus de documents XML. Evaluation d'une méthode approchée de RI structurée

We propose specific data structures designed to the indexing and retrieval of information elements in heterogeneous XML data bases. The indexing scheme is well suited to the management of various contextual searches, expressed either at a structural level or at an information content level. The approximate search mechanisms are based on a modified Levenshtein editing distance and information fusion heuristics. The implementation described highlights the mixing of structured information presented as field/value instances and free text elements. The retrieval performances of the proposed approach are evaluated within the INEX 2005 evaluation campaign. The evaluation results rank the proposed approach among the best evaluated XML IR systems for the VVCAS task.

A model for the definition of concepts

The pattern of existing terminological definitions is analysed, and a model for the terminological definition of concepts is proposed that is considered more appropriate to data-processing applications than present patterns of definition. The model consists of a regularised form of the traditional analytical definition by categorising and restricting the modes of description and thereby reducing the free-text element in the defining phrase. The new model should permit automatic prompting and control of the defining activity, highly efficient data storage and greater information extraction in retrieval. The model is currently being tested in a real application.