Interface terminologies: facilitating direct entry of clinical data into electronic health record systems.
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TLDR
The historical goals and challenges of clinical terminology development in general and the unique features of interface terminologies are reviewed and a focus is focused on those that support a balance between pre- and post-coordination.About:
This article is published in Journal of the American Medical Informatics Association.The article was published on 2006-05-01 and is currently open access. It has received 216 citations till now. The article focuses on the topics: Terminology & MEDCIN.read more
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A new sociotechnical model for studying health information technology in complex adaptive healthcare systems
Dean F. Sittig,Hardeep Singh +1 more
TL;DR: An eight-dimensional model specifically designed to address the sociotechnical challenges involved in design, development, implementation, use and evaluation of HIT within complex adaptive healthcare systems is introduced.
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Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA
Blackford Middleton,Meryl Bloomrosen,Mark A. Dente,Bill Hashmat,Ross Koppel,J. Marc Overhage,Thomas H. Payne,S. Trent Rosenbloom,Charlotte A. Weaver,Jiajie Zhang +9 more
TL;DR: These AMIA recommendations are intended to stimulate informed debate, provide a plan to increase understanding of the impact of usability on the effective use of health IT, and lead to safer and higher quality care with the adoption of useful and usable EHR systems.
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Data from clinical notes: a perspective on the tension between structure and flexible documentation.
S. Trent Rosenbloom,Joshua C. Denny,Hua Xu,Nancy M. Lorenzi,William W. Stead,Kevin B. Johnson +5 more
TL;DR: The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs.
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Electronic health records. A systematic review on quality requirements.
TL;DR: The present review aims at describing the currently available, mainly non-functional, quality requirements with regard to electronic health records by using systematic literature analysis and expert interviews to identify requirements.
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Surgical process modelling: a review
TL;DR: A review of the literature dealing with surgical process modelling allows a greater understanding of the SPM field to be gained and introduces future related prospects.
References
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Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors
TL;DR: With a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.
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Ten Commandments for Effective Clinical Decision Support: Making the Practice of Evidence-based Medicine a Reality
David W. Bates,Gilad J. Kuperman,Gilad J. Kuperman,Samuel J. Wang,Tejal K. Gandhi,Anne F. Kittler,Lynn A. Volk,Cynthia D. Spurr,Ramin Khorasani,Milenko J. Tanasijevic,Blackford Middleton,Blackford Middleton +11 more
TL;DR: Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success, which should result in improved quality of care.
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Internist-I, an Experimental Computer-Based Diagnostic Consultant for General Internal Medicine
TL;DR: It is demonstrated that the present form of the INTERNIST-I program is not sufficiently reliable for clinical applications and specific deficiencies that must be overcome include the program’s inability to reason anatomically or temporally, its inability to construct differential diagnoses spanning multiple problem areas, and its occasional attribution of findings to improper causes.
Book
The Computer-Based Patient Record: An Essential Technology for Health Care
Elaine B. Steen,Don E. Detmer +1 more
TL;DR: This revised edition adds new information to the original book, including the creation of a computer-based patient record institute in the United States - a strategy recommended in the original volume to promote and facilitate implementation of the CPR.
Journal ArticleDOI
Desiderata for Controlled Medical Vocabularies in the Twenty-First Century
TL;DR: This paper brings together some of the common themes which have been described, including: vocabulary content, concept orientation, concept Orientation, concept permanence, nonsemantic concept identifiers, polyhierarchy, formal definitions, rejection of "not elsewhere classified" terms, multiple granularities, multiple consistent views, context representation, graceful evolution, and recognized redundancy.