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OBJECTIVE In this study the authors describe the system submitted by the team of University of Szeged to the second i2b2 Challenge in Natural Language Processing for Clinical Data. The challenge focused on the development of automatic systems that analyzed clinical discharge summary texts and addressed the following question: "Who's obese and what co-morbidities do they (definitely/most likely) have?". Target diseases included obesity and its 15 most frequent comorbidities exhibited [...]

OBJECTIVE Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability. METHODS The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality [...]

Errors associated with medication documentation account for a substantial fraction of preventable medical errors. Hence, the Joint Commission has called for the adoption of reconciliation strategies at all United States healthcare institutions. Although studies suggest that reconciliation tools can reduce errors, it remains unclear how best to implement systems and processes that are reliable and sensitive to clinical workflow. The authors designed a primary care process that supported reconciliation without [...]

The authors summarize their experience in iteratively testing the adequacy of three versions of the Health Level Seven (HL7) Logical Observation Identifiers Names and Codes (LOINC) Clinical Document Ontology (CDO) to represent document names at Columbia University Medical Center. The percentage of documents fully represented increased from 23.4% (Version 1) to 98.5% (Version 3). The proportion of unique representations increased from 7.9% (Analysis 1) to 39.4% (Analysis 4); the proportion [...]

To assess the performance of electronic health record data for syndromic surveillance and to assess the feasibility of broadly distributed surveillance.

To identify some of the challenges that medical residents face in addressing their information needs in an inpatient setting, by examining how voice capture in natural language of clinical questions fits into workflow, and by characterizing the focus, format, and semantic content and complexity of their questions.

The Canadian Health Outcomes for Better Information and Care (C-HOBIC) project introduced systematic use of standardized clinical nursing terminology for patient assessments. Implemented so far in three Canadian provinces, C-HOBIC comprises an innovative model for large-scale capture of standardized nursing-sensitive clinical outcomes data within electronic health records (EHRs). To support this activity, nursing assessment and outcomes concepts were mapped to the International Classification for Nursing Practice (ICNP(R)). By comparing serial [...]

Clinical Research Informatics, an emerging sub-domain of Biomedical Informatics, is currently not well defined. A formal description of CRI including major challenges and opportunities is needed to direct progress in the field.

The purpose of this study is to reassess the projected rate of Electronic Health Record (EHR) diffusion and examine how the federal government's efforts to promote the use of EHR technology have influenced physicians' willingness to adopt such systems. The study recreates and extends the analyses conducted by Ford et al. (1) The two periods examined come before and after the U.S. Federal Government's concerted activity to promote EHR adoption.

Medication errors constitute a major problem in all hospitals. Between 20% and 46% of prescriptions requiring dosage adjustments based on renal function are inappropriate. This study aimed to determine whether implementing alerts at the time of ordering medication integrated into the computerized physician order entry decreases the proportion of inappropriate prescriptions based on the renal function of inpatients.