A principal goal of computerisation of medical records is to join up care
services for patients, so that their records can follow them wherever they go
and thereby reduce delays, duplications, risks and errors, and costs. Healthcare
records are increasingly being stored electronically, which has created the
necessary conditions for them to be readily sharable. However simply driving the
implementation of electronic medical records is not sufficient, as recent
developments have demonstrated (1): there remain significant obstacles.
The three main obstacles relate to (a) record accessibility (knowing where event
records are and being able to access them), (b) maintaining privacy (ensuring
that only those authorised by the patient can access and extract meaning from
the records) and (c) assuring the functionality of the shared information
(ensuring that the records can be shared non-proprietorially across platforms
without loss of meaning, and that their authenticity and trustworthiness are
demonstrable). These constitute a set of issues that need new thinking, since
existing systems are struggling to deliver them.
The solution to this puzzle lies in three main parts. Clearly there is only one
environment suited to such widespread sharing, which is the World Wide Web, so
this is the communications basis. Part one requires that a sharable synoptic
record is created for each care event and stored in standard web-format and in
readily accessible locations, on ‘the web’ or in ‘the
cloud’. To maintain privacy these publicly-accessible records must be
suitably protected either stripped of identifiers (names, addresses, dates,
places etc.) and/or encrypted: either way the record must be tagged with a tag
that means nothing to anyone, but serves to identify and authenticate a specific
record when retrieved. For ease of retrieval patients must hold an index of care
events, records and web locations (plus any associated information for each such
as encryption keys, context etc.). For added security, as well as for
trustworthiness, a method of verifying authenticity, integrity and authorship is
required, which can be provided using a public key infrastructure (PKI) for
cryptography (2). The second part of the solution is to give control over record
access and sharing to the patient (or their identified representative), enabling
them to authorise access by providing the index and access keys to their
records. This can be done using a token (fe.g. smart card) or a secure online
index which holds these details: this serves to relieve the formal record keeper
of responsibility for external access control and privacy (internal access
control and privacy can remain an institutional responsibility). The third part
of the solution is to process the content of the stored records such that there
is a ‘plain English’ copy, as well as an electronic copy which is
coded and marked up using XML tags for each data element to signify
‘type’ (e.g. administrative, financial, operational, clinical
etc.) and sub-types (e.g. diagnosis, medication, procedure,
investigation result etc.). This ensures that the recipient can always read the
data using a basic browser, but can readily manipulate and re-arrange the data
for display and storage if they have a more sophisticated installation.
Smoking is a UK public health threat but GPs can be effective in helping patients
to quit; consequently, the Quality and Outcomes Framework (QOF) incentivises the
recording of smoking status and delivery of cessation advice in patients’
medical records. This study investigates the association between smoking-related
QOF targets and such recording, and the factors which influence these clinical
For 2000 to 2008, using medical records in The Health Improvement Network (THIN)
database, the annual proportions of i) patients who had a record of smoking status
made in the previous 27 months and ii) current smokers recorded as receiving
cessation advice in the previous 15 months were calculated. Then, for all
patients at selected points before and after the QOF’s implementation, data
on gender, age, Townsend score, and smoking-related morbidity were extracted.
Multivariate logistic regression was used to investigate individual-level
characteristics associated with the recording of smoking status and cessation
Rapid increases in recording smoking status and advice occurred around the
QOF’s introduction in April 2004. Subsequently, compliance to targets has
been sustained, although rates of increase have slowed. By 2008 64.5% of patients
aged 15+ had smoking status documented in the previous 27 months and 50.5%
of current smokers had cessation advice recorded in the last 15 months.
Adjusted odds ratios show that, both before and after the introduction of the QOF,
those with chronic medical conditions, greater social deprivation and women were
more likely to have a recent recording of smoking status or cessation advice.
Since the QOF’s introduction, the strongest characteristic associated with
recording activities was the presence of co-morbidity. An example of this was
patients with COPD, who in 2008, were 15.38 (95% CI 13.70-17.27) times and 11.72
(95% CI 10.41-13.21) times more likely to have a record of smoking status and
cessation advice, respectively.
Rates of recording smoking status and cessation advice plateaued after large
increases during the QOF’s introduction; however, recording remains most
strongly associated with the presence of chronic disease as specified by the QOF,
and suggests that incentivised targets have a direct effect on clinical
Smoking; Quality and Outcomes Framework (QOF); Targets
To be able to monitor and protect endangered species, we need accurate information on their numbers and where they live. Survey methods using automated bioacoustic recorders offer significant promise, especially for species whose behaviour or ecology reduces their detectability during traditional surveys, such as the European nightjar. In this study we examined the utility of automated bioacoustic recorders and the associated classification software as a way to survey for wildlife, using the nightjar as an example. We compared traditional human surveys with results obtained from bioacoustic recorders. When we compared these two methods using the recordings made at the same time as the human surveys, we found that recorders were better at detecting nightjars. However, in practice fieldworkers are likely to deploy recorders for extended periods to make best use of them. Our comparison of this practical approach with human surveys revealed that recorders were significantly better at detecting nightjars than human surveyors: recorders detected nightjars during 19 of 22 survey periods, while surveyors detected nightjars on only six of these occasions. In addition, there was no correlation between the amount of vocalisation captured by the acoustic recorders and the abundance of nightjars as recorded by human surveyors. The data obtained from the recorders revealed that nightjars were most active just before dawn and just after dusk, and least active during the middle of the night. As a result, we found that recording at both dusk and dawn or only at dawn would give reasonably high levels of detection while significantly reducing recording time, preserving battery life. Our analyses suggest that automated bioacoustic recorders could increase the detection of other species, particularly those that are known to be difficult to detect using traditional survey methods. The accuracy of detection is especially important when the data are used to inform conservation.
Elimination of kala-azar is planned for South Asia requiring good surveillance along with other strategies. We assessed surveillance in Gaffargaon upazila (a subdistrict of 13 unions) of Mymensingh district, Bangladesh highly endemic for kala-azar.
In 4703 randomly sampled households, within nine randomly sampled villages, drawn from three randomly sampled unions, we actively searched for kala-azar cases that had occurred between January 2010 and December 2011. We then searched for medical records of these cases in the patient registers of Gaffargaon upazila health complex (UHC). We investigated factors associated with the medical recording by interviewing the cases and their families. We also did a general observation of UHC recording systems and interviewed health staff responsible for the monthly reports of kala-azar cases.
Our active case finding detected 58 cases, but 29 were not recorded in the Gaffargaon UHC. Thus, only 50% (95% CI: 37%–63%) of kala-azar cases were reported via the government passive surveillance system. Interviews with health staff based in the study UHC revealed the heavy reporting burden for multiple diseases, variation in staff experience, high demands on the staff time and considerable complexity in the recording system. After adjusting for kala-azar treatment drug, recording was found more likely for those aged 18 years or more, males, receiving supply and administration of drug at the UHC, and more recent treatment.
Fifty percent of kala-azar cases occurring in one highly endemic area of Bangladesh were recorded in registers that were the source for monthly reports to the national surveillance system. Recording was influenced by patient, treatment, staff and system factors. Our findings have policy implications for the national surveillance system. Future studies involving larger samples and including interviews with health authorities at more central level and surveillance experts at the national level will generate more precise and representative evidence on the performance of kala-azar surveillance in Bangladesh.
Visceral leishmaniasis, a parasitic disease transmitted by sandflies, is known as kala-azar in South Asia, and has been targeted for elimination in that region. The aim is to reduce its incidence to a low level so that it is no longer a public health problem. Elimination strategies include good surveillance for occurrence of the disease. We assessed surveillance in Gaffargaon subdistrict of Mymensingh district in Bangladesh where occurrence of kala-azar is high. We randomly sampled 4703 households and searched for kala-azar cases that had occurred between January 2010 and December 2011. We then searched for medical records of these cases in the patient registers of Gaffargaon upazila or subdistrict health complex (UHC). We interviewed cases, their families and health staff responsible for the monthly reports of kala-azar. We also observed the UHC recording system. We detected 58 cases, but 29 (50%) were not recorded in the Gaffargaon UHC. Problems include the heavy reporting burden for multiple diseases, variation in staff experience, high demands on the staff time and complexity in the recording system. Recording was more likely for adults, males, those given drugs at the UHC, and more recent treatment. Our findings have implications for kala-azar surveillance.
Recent advances in the technology of recording magnetic fields associated with electric current flow in biological tissues have provided a means of examining action currents that is more direct and possibly more accurate than conventional electrical recording. Magnetic recordings are relatively insensitive to muscle movement, and, because the recording probes are not directly connected to the tissue, distortions of the data due to changes in the electrochemical interface between the probes and the tissue are eliminated. In vivo magnetic recordings of action currents of rat common peroneal nerve and extensor digitorum longus (EDL) muscle were obtained by a new magnetic probe and amplifier system that operates within the physiological temperature range. The magnetically recorded waveforms were compared with those obtained simultaneously by conventional, extracellular recording techniques. We used the amplitude of EDL twitch force (an index of stimulus strength) generated in response to graded stimulation of the common peroneal nerve to enable us to compare the amplitudes of magnetically recorded nerve and muscle compound action currents (NCACs and MCACs, respectively) with the amplitudes of electrically recorded nerve compound action potentials (NCAPs). High, positive correlations to stimulus strength were found for NCACs (r = 0.998), MCACs (r = 0.974), and NCAPs (r = 0.998). We also computed the correlations of EDL single motor unit twitch force with magnetically recorded single motor unit compound action currents (SMUCACs) and electrically recorded single motor unit compound action potentials (SMUCAPs) obtained with both a ring electrode and a straight wire serving as a point electrode. Only the SMUCACs had a relatively strong positive correlation (r = 0.768) with EDL twitch force. Correlations for ring and wire electrode- recorded SMUCAPs were 0.565 and -0.366, respectively. This study adds a relatively direct examination of action currents to the characterization of the normal biophysical properties of peripheral nerve, muscle, and muscle single motor units.
United Kingdom (UK) national guidelines recommend that all pregnant women who smoke should be advised to quit at every available opportunity, and brief cessation advice is an efficient and cost-effective means to increase quit rates. The Quality and Outcomes Framework (QOF) implemented in 2004 requires general practitioners to document their delivery of smoking cessation advice in patient records. However, no specific targets have been set in QOF for the recording of this advice in pregnant women. We used a large electronic primary care database from the UK to quantify the pregnancies in which women who smoked were recorded to have been given smoking cessation advice, and the associated maternal characteristics.
Using The Health Improvement Network database we calculated annual proportions of pregnant smokers between 2000 and 2009 with cessation advice documented in their medical records during pregnancy. Logistic regression was used to assess variation in the recording of cessation advice with maternal characteristics.
Among 45,296 pregnancies in women who smoked, recorded cessation advice increased from 7% in 2000 to 37% in 2004 when the QOF was introduced and reduced slightly to 30% in 2009. Pregnant smokers from the youngest age group (15–19) were 21% more likely to have a record of cessation advice compared to pregnant smokers aged 25–29 (OR 1.21, 95% CI 1.10-1.35) and pregnant smokers from the most deprived group were 38% more likely to have a record for cessation advice compared to pregnant smokers from the least deprived group (OR 1.38, 95% CI 1.14-1.68). Pregnant smokers with asthma were twice as likely to have documentation of cessation advice in their primary care records compared to pregnant smokers without asthma (OR 1.97, 95% CI 1.80-2.16). Presence of comorbidities such as diabetes, hypertension and mental illness also increased the likelihood of having smoking cessation advice recorded. No marked variations were observed in the recording of cessation advice with body mass index.
Recorded delivery of smoking cessation advice for pregnant smokers in primary care has increased with some fluctuation over the years, especially after the implementation of the QOF, and varies with maternal characteristics.
Pregnancy; Smoking; Primary care; Smoking cessation advice
Given the health impacts of smoking during pregnancy and the opportunity for primary healthcare teams to encourage pregnant smokers to quit, our primary aim was to assess the completeness of gestational smoking status recording in primary care data and investigate whether completeness varied with women's characteristics. As a secondary aim we assessed whether completeness of recording varied before and after the introduction of the Quality and Outcomes Framework (QOF).
In The Health Improvement Network (THIN) database we calculated the proportion of pregnancies ending in live births or stillbirths where there was a recording of maternal smoking status for each year from 2000 to 2009. Logistic regression was used to assess variation in the completeness of maternal smoking recording by maternal characteristics, before and after the introduction of QOF.
Women had a record of smoking status during the gestational period in 28% of the 277,552 pregnancies identified. In 2000, smoking status was recorded in 9% of pregnancies, rising to 43% in 2009. Pregnant women from the most deprived group were 17% more likely to have their smoking status recorded than pregnant women from the least deprived group before QOF implementation (OR 1.17, 95% CI 1.10–1.25) and 42% more likely afterwards (OR 1.42, 95% CI 1.37–1.47). A diagnosis of asthma was related to recording of smoking status during pregnancy in both the pre-QOF (OR 1.63, 95% CI 1.53–1.74) and post-QOF periods (OR 2.08, 95% CI 2.02–2.15). There was no association between having a diagnosis of diabetes and recording of smoking status during pregnancy pre-QOF however, post-QOF diagnosis of diabetes was associated with a 12% increase in recording of smoking status (OR 1.12, 95% CI 1.05–1.19).
Recording of smoking status during pregnancy in primary care data is incomplete though has improved over time, especially after the implementation of the QOF, and varies by maternal characteristics and QOF-incentivised morbidities.
The provision of appropriate care along the continuum of maternal, newborn, and child health (MNCH) service delivery is a challenge in developing countries. To improve this, in the 1990s, Indonesia introduced the maternal and child health (MCH) handbook, as an integrated form of parallel home-based records.
This study aimed to identify the roles of home-based records both before and after childbirth, especially in provinces where the MCH handbook (MCHHB) was extensively promoted, by examining their association with MNCH service uptake.
This was a cross-sectional study using nationally representative data sets, the Indonesia Demographic and Health Surveys (IDHSs) from 1997, 2002–2003, and 2007. The IDHS identifies respondents’ ownership of home-based records before and after childbirth. Multivariate logistic regression was used to examine associations between record ownership and service utilisation in national data and data from two provinces, West Sumatra and North Sulawesi, where ownership of pre- and post-natal records served as a proxy for MCHHB ownership.
Pre- and post-natal record ownership increased from 1997 to 2007. Provincial data from 2007 showed that handbook ownership was associated with having delivery assisted by trained personnel [adjusted odds ratio (aOR): 2.12, 95% confidence interval (CI): 1.05–4.25], receiving maternal care (aOR: 3.92, 95% CI: 2.35–6.52), completing 12 doses of child immunisation for seven diseases (aOR: 4.86, 95% CI: 2.37–9.95), and having immunisation before and after childbirth (aOR: 5.40, 95% CI: 2.28–12.76), whereas national data showed that service utilisation was associated with ownership of both records compared with owning a single record or none.
Our results suggest that pre- and post-natal home-based record use may be effective for ensuring service utilisation. In addition, since the handbook is an efficient home-based record for use throughout children's life courses, it could be an effective tool for promoting the continuum of MNCH care in Indonesia.
continuum of care; maternal; newborn and child health; personal health record; Maternal and Child Health handbook; Indonesia
Providers’ adoption of electronic health records (EHRs) is increasing and consumers have expressed concerns about the potential effects of EHRs on privacy and security. Yet, we lack a comprehensive understanding regarding factors that affect individuals’ perceptions regarding the privacy and security of their medical information.
The aim of this study was to describe national perceptions regarding the privacy and security of medical records and identify a comprehensive set of factors associated with these perceptions.
Using a nationally representative 2011-2012 survey, we reported on adults’ perceptions regarding privacy and security of medical records and sharing of health information between providers, and whether adults withheld information from a health care provider due to privacy or security concerns. We used multivariable models to examine the association between these outcomes and sociodemographic characteristics, health and health care experience, information efficacy, and technology-related variables.
Approximately one-quarter of American adults (weighted n=235,217,323; unweighted n=3959) indicated they were very confident (n=989) and approximately half indicated they were somewhat confident (n=1597) in the privacy of their medical records; we found similar results regarding adults’ confidence in the security of medical records (very confident: n=828; somewhat confident: n=1742). In all, 12.33% (520/3904) withheld information from a health care provider and 59.06% (2100/3459) expressed concerns about the security of both faxed and electronic health information. Adjusting for other characteristics, adults who reported higher quality of care had significantly greater confidence in the privacy and security of their medical records and were less likely to withhold information from their health care provider due to privacy or security concerns. Adults with higher information efficacy had significantly greater confidence in the privacy and security of medical records and less concern about sharing of health information by both fax and electronic means. Individuals’ perceptions of whether their providers use an EHR was not associated with any privacy or security outcomes.
Although most adults are confident in the privacy and security of their medical records, many express concerns regarding sharing of information between providers; a minority report withholding information from their providers due to privacy and security concerns. Whether individuals thought their provider was using an EHR was not associated with negative privacy/security perceptions or withholding, suggesting the transition to EHRs is not associated with negative perceptions regarding the privacy and security of medical information. However, monitoring to see how this evolves will be important. Given that positive health care experiences and higher information efficacy were associated with more favorable perceptions of privacy and security, efforts should continue to encourage providers to secure medical records, provide patients with a “meaningful choice” in how their data are shared, and enable individuals to access information they need to manage their care.
electronic health records; privacy confidentiality; health information exchange; health surveys; health knowledge; attitudes; practice
Objective To clinically evaluate a new patented multimodal system (SAFERSleep) designed to reduce errors in the recording and administration of drugs in anaesthesia.
Design Prospective randomised open label clinical trial.
Setting Five designated operating theatres in a major tertiary referral hospital.
Participants Eighty nine consenting anaesthetists managing 1075 cases in which there were 10 764 drug administrations.
Intervention Use of the new system (which includes customised drug trays and purpose designed drug trolley drawers to promote a well organised anaesthetic workspace and aseptic technique; pre-filled syringes for commonly used anaesthetic drugs; large legible colour coded drug labels; a barcode reader linked to a computer, speakers, and touch screen to provide automatic auditory and visual verification of selected drugs immediately before each administration; automatic compilation of an anaesthetic record; an on-screen and audible warning if an antibiotic has not been administered within 15 minutes of the start of anaesthesia; and certain procedural rules—notably, scanning the label before each drug administration) versus conventional practice in drug administration with a manually compiled anaesthetic record.
Main outcome measures Primary: composite of errors in the recording and administration of intravenous drugs detected by direct observation and by detailed reconciliation of the contents of used drug vials against recorded administrations; and lapses in responding to an intermittent visual stimulus (vigilance latency task). Secondary: outcomes in patients; analyses of anaesthetists’ tasks and assessments of workload; evaluation of the legibility of anaesthetic records; evaluation of compliance with the procedural rules of the new system; and questionnaire based ratings of the respective systems by participants.
Results The overall mean rate of drug errors per 100 administrations was 9.1 (95% confidence interval 6.9 to 11.4) with the new system (one in 11 administrations) and 11.6 (9.3 to 13.9) with conventional methods (one in nine administrations) (P=0.045 for difference). Most were recording errors, and, though fewer drug administration errors occurred with the new system, the comparison with conventional methods did not reach significance. Rates of errors in drug administration were lower when anaesthetists consistently applied two key principles of the new system (scanning the drug barcode before administering each drug and keeping the voice prompt active) than when they did not: mean 6.0 (3.1 to 8.8) errors per 100 administrations v 9.7 (8.4 to 11.1) respectively (P=0.004). Lapses in the vigilance latency task occurred in 12% (58/471) of cases with the new system and 9% (40/473) with conventional methods (P=0.052). The records generated by the new system were more legible, and anaesthetists preferred the new system, particularly in relation to long, complex, and emergency cases. There were no differences between new and conventional systems in respect of outcomes in patients or anaesthetists’ workload.
Conclusions The new system was associated with a reduction in errors in the recording and administration of drugs in anaesthesia, attributable mainly to a reduction in recording errors. Automatic compilation of the anaesthetic record increased legibility but also increased lapses in a vigilance latency task and decreased time spent watching monitors.
Trial registration Australian New Zealand Clinical Trials Registry No 12608000068369.
A condition to predict unbiased estimated breeding values by best linear unbiased prediction is to use simultaneously all available data. However, this condition is not often fully met. For example, in dairy cattle, internal (i.e. local) populations lead to evaluations based only on internal records while widely used foreign sires have been selected using internally unavailable external records. In such cases, internal genetic evaluations may be less accurate and biased. Because external records are unavailable, methods were developed to combine external information that summarizes these records, i.e. external estimated breeding values and associated reliabilities, with internal records to improve accuracy of internal genetic evaluations. Two issues of these methods concern double-counting of contributions due to relationships and due to records. These issues could be worse if external information came from several evaluations, at least partially based on the same records, and combined into a single internal evaluation. Based on a Bayesian approach, the aim of this research was to develop a unified method to integrate and blend simultaneously several sources of information into an internal genetic evaluation by avoiding double-counting of contributions due to relationships and due to records.
This research resulted in equations that integrate and blend simultaneously several sources of information and avoid double-counting of contributions due to relationships and due to records. The performance of the developed equations was evaluated using simulated and real datasets. The results showed that the developed equations integrated and blended several sources of information well into a genetic evaluation. The developed equations also avoided double-counting of contributions due to relationships and due to records. Furthermore, because all available external sources of information were correctly propagated, relatives of external animals benefited from the integrated information and, therefore, more reliable estimated breeding values were obtained.
The proposed unified method integrated and blended several sources of information well into a genetic evaluation by avoiding double-counting of contributions due to relationships and due to records. The unified method can also be extended to other types of situations such as single-step genomic or multi-trait evaluations, combining information across different traits.
Electronic supplementary material
The online version of this article (doi:10.1186/s12711-014-0059-3) contains supplementary material, which is available to authorized users.
Mobile technologies are emerging as valuable tools to collect and assess dietary intake. Adolescents readily accept and adopt new technologies; thus, a food record app (FRapp) may be a useful tool to better understand adolescents’ dietary intake and eating patterns.
We sought to determine the amenability of adolescents, in a free-living environment with minimal parental input, to use the FRapp to record their dietary intake.
Eighteen community-dwelling adolescents (11-14 years) received detailed instructions to record their dietary intake for 3-7 days using the FRapp. Participants were instructed to capture before and after images of all foods and beverages consumed and to include a fiducial marker in the image. Participants were also asked to provide text descriptors including amount and type of all foods and beverages consumed.
Eight of 18 participants were able to follow all instructions: included pre- and post-meal images, a fiducial marker, and a text descriptor and collected diet records on 2 weekdays and 1 weekend day. Dietary intake was recorded on average for 3.2 (SD 1.3 days; 68% weekdays and 32% weekend days) with an average of 2.2 (SD 1.1) eating events per day per participant. A total of 143 eating events were recorded, of which 109 had at least one associated image and 34 were recorded with text only. Of the 109 eating events with images, 66 included all foods, beverages and a fiducial marker and 44 included both a pre- and post-meal image. Text was included with 78 of the captured images. Of the meals recorded, 36, 33, 35, and 39 were breakfasts, lunches, dinners, and snacks, respectively.
These data suggest that mobile devices equipped with an app to record dietary intake will be used by adolescents in a free-living environment; however, a minority of participants followed all directions. User-friendly mobile food record apps may increase participant amenability, increasing our understanding of adolescent dietary intake and eating patterns. To improve data collection, the FRapp should deliver prompts for tasks, such as capturing images before and after each eating event, including the fiducial marker in the image, providing complete and accurate text information, and ensuring all eating events are recorded and should be customizable to individuals and to different situations.
Clinicaltrials.gov NCT01803997. http://clinicaltrials.gov/ct2/show/NCT01803997 (Archived at: http://www.webcitation.org/6WiV1vxoR).
adolescents; dietary food records; smartphone app; dietary assessment; food record app
Obesity is a prevalent medical condition in dogs caused by the excess accumulation of fat, with negative effects on quality of life, longevity and the risk of developing associated pathologies. However, it is unclear how frequently first-opinion veterinarians record dogs as overweight (OW) or obese in medical records, and what factors determine when they do. Data sourced through the Small Animal Surveillance Network were used to determine the relative frequency of recording OW status (obesity or OW) in dogs presented to the UK first-opinion practices. Cases were identified using a search of clinical record-free text for relevant keywords. A case–control study was then conducted, comparing dogs where the OW status was recorded with a control group of obese dogs with no diagnosis recorded. Of 49 488 consultations, the OW status was recorded in 671 dogs (relative frequency 1·4 %). Using multiple logistic regression, the OW status of a dog was more likely to be recorded when the consultation was for osteoarthritis (OR 5·42; 95 % CI 2·09, 14·07; P < 0·001) or lameness (OR 2·02; 95 % CI 1·20, 3·42; P = 0·006). Furthermore, the OW status was more commonly recorded in dogs that were members of a practice health scheme (OR 5·35; 95 % CI 1·57, 18·17; P = 0·04) and less commonly recorded in microchipped dogs (OR 0·43; 95 % CI 0·41, 0·91; P = 0·02). These results suggest that OW and obesity are underdiagnosed in the first-opinion practice. However, a presentation for orthopaedic disease appears a key prompt for recording the OW status. Further studies are now warranted to determine the reasons for such marked underdiagnosis.
Obesity; Canine nutrition; Practice surveillance; BCS, body condition score; NSAID, non-steroidal anti-inflammatory drug; OW, overweight
Introduction and Objectives:
In recent times, audio-video (A-V) recording of consent process for all the study subjects entering a clinical trial has been made mandatory. A-V recording of informed consent process is a big challenge due to confidentiality and the sociocultural environment in India. It is important to find out the acceptability for A-V recording of the consent process and reasons for refusal, if any to address this new challenge.
Materials and Methods:
A descriptive survey was done among 150 residents of a rural community of South India. Acceptability for A-V recording of consent process was assessed among those who had given the informed written consent for participation in the study. An attempt to find the factors determining the refusal was also made.
More than one-third (34%) of the study subjects refused to give consent for A-V recording of consent process. Not interested in recording or don’t like to be recorded (39%) were the most common reasons to refuse for A-V recording of consent process. The refusal was higher among female and younger age-group adult subjects. Socioeconomic status was not found to be significantly associated with refusal to consent for A-V recording.
Refusal for A-V recording of consent process is high in the South Indian rural population. Before any major clinical trial, particularly a field trial, an assessment of consent for A-V recording would be helpful in recruitment of study subjects.
Audio-video recording; clinical trials; informed consent
An analysis has been made of the electrical responses recorded on the surface and within the substance of the first sacral spinal segment when the contained motoneurons are excited by single and repeated antidromic ventral root volleys. A succession of negative deflections, designated in order of increasing latency m, i, b, d, has been found. Each of those deflections possesses some physiological property or properties to distinguish it from the remainder. Indicated by that fact is the conclusion that the successive deflections represent impulse conduction through successive parts of the motoneurons that differ in behavior, each from the others. Since the spinal cord constitutes a volume conductor the negative deflections are anteceded by a positive deflection at all points except that at which the axonal impulses first enter from the ventral root into the spinal cord. Frequently two or more negative deflections are recorded together in overlapping sequence, but for each deflection a region can be found in which the onset of that deflection marks the transition from prodromal positivity to negativity. Deflection m is characteristic of axonal spikes. Latent period is in keeping with known axonal conduction velocity. Refractory period is brief. The response represented by m is highly resistant to asphyxia. Maximal along the line of ventral root attachment and attenuating sharply therefrom, deflection m can be attributed only to axonal impulse conduction. Deflection i is encountered only within the cord, and is always associated with a deflection b. The i,b complex is recordable at loci immediately dorsal to regions from which m is recorded, and immediately ventral to points from which b is recorded in isolation from i. Except for its great sensitivity to asphyxia, deflection i has properties in common with those of m, but very different from those of b or d. To judge by properties i represents continuing axonal impulse conduction into a region, however, that is readily depolarized by asphyxia. Deflection b possesses a unique configuration in that the ascending limb is sloped progressively to the right indicating a sharp decrease in velocity of the antidromic impulses penetrating the b segment. A second antidromic volley will not conduct from i segment to b segment of the motoneurons unless separated from the first by nearly 1 msec. longer than is necessary for restimulation of axons. This value accords with somatic refractoriness determined by other means. Together with spatial considerations, the fact suggests that b represents antidromic invasion of cell bodies. Deflection d is ubiquitous, but in recordings from regions dorsal and lateral to the ventral horn, wherein an electrode is close to dendrites, but remote from other segments of motoneurons, d is the initial negative deflection. In latency d is variable to a degree that demands that it represent slow conduction through rather elongated structures. When associated with deflection b, deflection d may arise from the peak of b with the only notable discontinuity provided by the characteristically sloped rising phase of b. Deflection d records the occupation by antidromic impulses of the dendrites. Once dendrites have conducted a volley they will not again do so fully for some 120 msec. Embracing the several deflections, recorded impulse negativity in the motoneurons may endure for nearly 5 msec. When the axonal deflection m is recorded with minimal interference from somatic currents, it is followed by a reversal of sign to positivity that endures as long as impulse negativity can be traced elsewhere, demonstrating the existence of current flow from axons to somata as the latter are occupied by impulses. Note is taken of the fact that impulse conduction through motoneurons is followed by an interval, measurable to some 120 msec., during which after-currents flow. These currents denote the existence in parts of the intramedullary motoneurons of after-potentials the courses of which must differ in different parts of the neurons, otherwise nothing would be recorded. The location of sources and sinks is such as to indicate that a major fraction of the current flows between axons and somata. For approximately 45 msec. the direction of flow is from dendrites to axons. Thereafter, and for the remaining measurable duration, flow is from axons to dendrites.
Health-related registries arose due from clinician desire to improve patient quality of care for a specific disorder. As such, disease registries differ from administrative registries in concept, organization, purpose, data recording, and results. Due to their voluntary nature, health-related disease registries are not regularly audited, have a narrow focus, and are designed for clinicians, not administrators. As part of a Department of Defense initiative we conducted an intensive qualitative review of the American Burn Association’s National Burn Repository (NBR). Our objectives are to inform future users of the NBR of issues that could affect statistical analyses and inferences and assist efforts to improve data collection.
We obtained a deidentified copy of the 2009 release of the NBR containing 286,293 records. We reviewed this data set for 1) records lacking vital patient information (age, burn size, survival, gender), 2) inconsistencies between data in different fields of the database, and 3) duplicate values.
Restricting our review to records with an admission year of 2000 or later, vital patient information was missing or invalid for about 60,000 records. Data inconsistencies were found in hospital admission status (initial admission or readmission) for about 12,000 records, survival for about 950 records, and burn injury for about 5,500 records. Depending on the criteria used to identify duplicate records, we found at least 4,000 duplicate records but as many as 14,000 in the database. Finally, significant data quality issues were found for facilities not using the TRACS software.
All health-related disease registries, unlike administrative databases, are voluntary. Anonymity of data is vital, and data auditing and reporting are challenging. The data contained in the NBR is disease-specific, and, as such, has the potential to provide valuable epidemiologic, treatment, and outcome data as reported by clinicians, not registrars. The NBR provides substantive data on burn injury; however, data review needs to precede data analysis. Revisions to NBR data collection have improved the quality of data submitted, yet data quality issues remain in the current database. Investigators are cautioned to thoroughly assess all fields prior to conducting analyses using the NBR.
National Burn Repository; health registry; burns
This paper describes AnthWest, a large dataset that represents one of the outcomes of a comprehensive, broadly comparative study on the diversity, biology, biogeography, and evolution of Anthidium Fabricius in the Western Hemisphere. In this dataset a total of 22,648 adult occurrence records comprising 9657 unique events are documented for 92 species of Anthidium, including the invasive range of two introduced species from Eurasia, A. oblongatum (Illiger) and A. manicatum (Linnaeus). The geospatial coverage of the dataset extends from northern Canada and Alaska to southern Argentina, and from below sea level in Death Valley, California, USA, to 4700 m a.s.l. in Tucumán, Argentina. The majority of records in the dataset correspond to information recorded from individual specimens examined by the authors during this project and deposited in 60 biodiversity collections located in Africa, Europe, North and South America. A fraction (4.8%) of the occurrence records were taken from the literature, largely California records from a taxonomic treatment with some additional records for the two introduced species. The temporal scale of the dataset represents collection events recorded between 1886 and 2012. The dataset was developed employing SQL server 2008 r2. For each specimen, the following information is generally provided: scientific name including identification qualifier when species status is uncertain (e.g. “Questionable Determination” for 0.4% of the specimens), sex, temporal and geospatial details, coordinates, data collector, host plants, associated organisms, name of identifier, historic identification, historic identifier, taxonomic value (i.e., type specimen, voucher, etc.), and repository. For a small portion of the database records, bees associated with threatened or endangered plants (~ 0.08% of total records) as well as specimens collected as part of unpublished biological inventories (~17%), georeferencing is presented only to nearest degree and the information on floral host, locality, elevation, month, and day has been withheld. This database can potentially be used in species distribution and niche modeling studies, as well as in assessments of pollinator status and pollination services. For native pollinators, this large dataset of occurrence records is the first to be simultaneously developed during a species-level systematic study.
Anthophila; Apoidea; bees; invasive species; North America; South America; pollinators; biodiversity; floral hosts
Poor to moderate validity of self-reported physical activity instruments is commonly observed in young people in low- and middle-income countries. However, the reasons for such low validity have not been examined in detail. We tested the validity of a self-administered daily physical activity record in adolescents and assessed if personal characteristics or the convenience level of reporting physical activity modified the validity estimates.
The study comprised a total of 302 adolescents from an urban and rural area in Ecuador. Validity was evaluated by comparing the record with accelerometer recordings for seven consecutive days. Test-retest reliability was examined by comparing registrations from two records administered three weeks apart. Time spent on sedentary (SED), low (LPA), moderate (MPA) and vigorous (VPA) intensity physical activity was estimated. Bland Altman plots were used to evaluate measurement agreement. We assessed if age, sex, urban or rural setting, anthropometry and convenience of completing the record explained differences in validity estimates using a linear mixed model.
Although the record provided higher estimates for SED and VPA and lower estimates for LPA and MPA compared to the accelerometer, it showed an overall fair measurement agreement for validity. There was modest reliability for assessing physical activity in each intensity level. Validity was associated with adolescents’ personal characteristics: sex (SED: P = 0.007; LPA: P = 0.001; VPA: P = 0.009) and setting (LPA: P = 0.000; MPA: P = 0.047). Reliability was associated with the convenience of completing the physical activity record for LPA (low convenience: P = 0.014; high convenience: P = 0.045).
The physical activity record provided acceptable estimates for reliability and validity on a group level. Sex and setting were associated with validity estimates, whereas convenience to fill out the record was associated with better reliability estimates for LPA. This tendency of improved reliability estimates for adolescents reporting higher convenience merits further consideration.
Accelerometers; Convenience; Diary; Ecuador; Low- and middle-income countries; Validity
OBJECTIVE--To describe the association of ethnic and socioeconomic status with recording of preventive care information by selected general practitioners. DESIGN--Random selection of people aged 20-64 registered with 43 general practitioners. Ethnic and social characteristics of stratified samples were determined at interview in the subject's home. Recording of preventive information was ascertained from general practitioners' medical records. SETTING--Inner London borough of Tower Hamlets. SUBJECTS--505 ut of 739 people confirmed as residents at their home address (190 white, 86 black, 112 Bangladeshi, 105 Chinese or Vietnamese, 12 other). MAIN OUTCOME MEASURES--Socioeconomic characteristics, consultation with general practitioner, and recorded preventive activities for ethnic groups. RESULTS--Minority ethnic groups were considerably more disadvantaged than white people and five times more likely to be overcrowded (31% v 6%), three times less likely to own their own home(11% v 37%), twice as likely to be in social classes IV and V (54% v 28%) and less likely to be employed (34% v 63%). There were no significant differences between white, black, Bangladeshi, and Chinese or Vietnamese subjects in recording smoking, blood pressure, alcohol consumption, weight, and height in the general practitioners' medical records. White women were more likely to have a record of mammography (46% v 20%; P=0.03) and of cervical smears than women in minority ethnic groups. CONCLUSION--Despite major socioeconomic inequity, equitable recording of preventive activity for the major causes of death for white, black and Bangladeshi populations is possible. Chinese and Vietnamese people had lower levels of recording and consultation. Mammography and, to a lesser extent, cervical cytology are inequitably recorded and require additional support at practice level.
BACKGROUND: Patient-held records can improve communication across the primary-secondary interface. There has been no previous rigorous assessment of the utility of patient-held records for people with schizophrenia from a primary care perspective and their value for this population is unclear. AIM: To evaluate the effectiveness of a patient-held record for patients with schizophrenia receiving shared care. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: Seventy-four general practices and six community mental health localities in Birmingham, England between June 1998 and June 1999. METHOD: A sample of 201 patients with schizophrenia (ICD-10 classification F20) was recruited; of these, 100 were intervention and 101 were control. Patient-held records were given to the intervention patients. At 12-month follow-up, all patients were accounted for and 191 (95%) were revisited. Primary outcomes were the Verona Service Satisfaction Scale-54 (VSSS-54) and the Krawiecka and Goldberg (K & G) rating scale of psychopathology at 12-month follow-up. Secondary outcomes were use of primary and secondary care services. RESULTS: A total of 63/92 (68.5%) patients still had the patient-held record, 64/92 (69.6%) had used it, and 39 (60.9%) of the 64 who had used it said the patient-held record was regularly used by their keyworker. However the patient-held record had no significant effect on primary outcomes (VSSS-54: F1,116 = 0.06, P = 0.801, K & G: F1,116 = 0.6, P = 0.439) or on use of services. A higher symptom score was associated with not using the patient-held record. CONCLUSIONS: The trial provides no good evidence to suggest that patient-held records should be introduced as part of routine shared care for all patients with schizophrenia. However, the patient-held record was acceptable to patients with schizophrenia and acted as a communication tool, particularly between patients and keyworkers.
Objective: To assess the effects of a computer-based patient record system on human cognition. Computer-based patient record systems can be considered "cognitive artifacts," which shape the way in which health care workers obtain, organize, and reason with knowledge.
Design: Study 1 compared physicians' organization of clinical information in paper-based and computer-based patient records in a diabetes clinic. Study 2 extended the first study to include analysis of doctor–patient–computer interactions, which were recorded on video in their entirety. In Study 3, physicians' interactions with computer-based records were followed through interviews and automatic logging of cases entered in the computer-based patient record.
Results: Results indicate that exposure to the computer-based patient record was associated with changes in physicians' information gathering and reasoning strategies. Differences were found in the content and organization of information, with paper records having a narrative structure, while the computer-based records were organized into discrete items of information. The differences in knowledge organization had an effect on data gathering strategies, where the nature of doctor-patient dialogue was influenced by the structure of the computer-based patient record system.
Conclusion: Technology has a profound influence in shaping cognitive behavior, and the potential effects of cognition on technology design needs to be explored.
To analyse the technical quality of electronic patient records in relation to legislation and to evaluate their quality associated with the quality of consultations as rated by patients and GPs.
Cross-sectional study of electronic patient records.
Four primary healthcare (PHC) centres in Finland using three different electronic patient record systems.
Patient records of 175 PHC consultations by 50 GPs, rated as the best (n=86) and the worst (n=89) of a total of 2191 consultations.
Main outcome measures
Documentation of records compared with legislation, the general informative value of records, and its relation to the experienced quality of consultations and to the electronic system employed.
Reason for encounter was mentioned in 79% of cases and patient history in 32%. An acute problem was described moderately well or well in 84%, examination findings in 62%, medical problem or diagnosis in 90%, and treatment in 95% of cases. Medication was documented adequately in 38% of the cases where medication was documented. Concerning general informative value, 18% were assessed as poor, 62% as moderate, and 20% as good. No correspondence was found between experienced quality of consultation and general informative value in the patient records. The quality of patient records was found to change according to the electronic system employed.
Finnish patient records are inadequate documents of consultations and below the standard of that country's legislation. Developing better models of recording would guarantee a higher quality of work.
Family medicine; family practice; patient record; quality of consultation
The introduction of different interocclusal recording materials has put clinicians in dilemma that which material should be used in routine clinical practice for precise recording and transferring of accurate existing occlusal records for articulation of patient’s diagnostic or working casts in the fabrication of good satisfactory prosthesis. In the era of developing world of dentistry the different materials are introduced for interocclusal record with different brand names because of this; the utility of the material is confusing for successful delivery of prosthesis with lack of in vitro or in vivo studies which will predict the property of the material with utility recommendations.
Purpose of the study
The aim of this multicenter research is to evaluate the time dependent linear dimensional stability of three types of interocclusal recording materials; which gives very clear idea to clinicians in regard to its usage in routine practice and recommendations for usage of the different materials. Also to find out ideal time for articulation of three types of interocclusal recording materials with accuracy.
Materials and method
Commercially available and ADA approved Polyether bite registration paste (Ramitec), Poly vinyl siloxane bite registration paste (Jetbite) and Zinc oxide eugenol (ZOE) bite registration paste (Super bite) were used in the study.
A stainless steel die was made according to modified American dental Associations (ADA) specification no. 19. Each one of the tested materials were manipulated according to manufacturers’ instructions. The materials separated from die, 3-mins after their respective setting time, resulted in disks of standard diameter. Two parallel lines and three perpendicular lines reproduced on the surface. The distance between two parallel lines was measured at different time intervals i.e. 1 hour, 24, 48 and 72 hours by using travelling microscope (magnus) and compared with standard die measurements made according to ADA specification no.19 to find out the dimensional stability of these interocclusal recording materials. Total 120 samples were made for observation and results were subjected to statistical analysis. Statistical analysis was performed using analysis of variance (ANOVA) and then Tukey’s Honestly Significant Difference (HSD) test for comparison among groups at the 0.05 level of significance. After statistical analysis of the data, results were obtained and analyzed for interpretation.
The results shows significant difference between the dimensional stability of all three material at different intervals with p-value <0.05. Comparatively the polyether bite registration material showed less distortion with good dimensional stability compared to Poly vinyl siloxane bite (Jetbite), Zinc oxide eugenol(ZOE) bite (Super bite) at 1 hour, 24, 48, and 72 hours.
The dimensional stability decreased with increase in time and is influenced by both material factor and time factor. Polyether was found to be more dimensionally stable interocclusal recording material, which was followed by Silicone and Zinc oxide eugenol (ZOE). The dimensional stability of Polyether was good. Zinc oxide eugenol is dimensionally more unstable when compared with polyether and polyvinyl siloxane. We recommend that the polyether interocclusal records must be articulated within 48 hours and Polyvinylsiloxane interocclusal records must be articulated within 24 hours and the ZOE should be articulated within 1 hour to get a correct restoration to have very minimum distortion and maximum satisfaction without failure of prosthesis.
Polyether bite; Poly vinyl siloxane bite; Zinc oxide eugenol (ZOE) bite; Dimensional stability; Interocclusal records
To compare the use of three electronic medical records systems by doctors in Norwegian hospitals for general clinical tasks.
Cross sectional questionnaire survey. Semistructured telephone interviews with key staff in information technology in each hospital for details of local implementation of the systems.
32 hospital units in 19 Norwegian hospitals with electronic medical records systems.
227 (72%) of 314 hospital doctors responded, equally distributed between the three electronic medical records systems.
Main outcome measures
Proportion of respondents who used the electronic system, calculated for each of 23 tasks; difference in proportions of users of different systems when functionality of systems was similar.
Most tasks listed in the questionnaire (15/23) were generally covered with implemented functions in the electronic medical records systems. However, the systems were used for only 2-7 of the tasks, mainly associated with reading patient data. Respondents showed significant differences in frequency of use of the different systems for four tasks for which the systems offered equivalent functionality. The respondents scored highly in computer literacy (72.2/100), and computer use showed no correlation with respondents' age, sex, or work position. User satisfaction scores were generally positive (67.2/100), with some difference between the systems.
Doctors used electronic medical records systems for far fewer tasks than the systems supported.
What is already known on this topicElectronic information systems in health care have not undergone systematic evaluation, and few comparisons between electronic medical records systems have been madeGiven the information intensive nature of clinical work, electronic medical records systems should be of help to doctors for most clinical tasksWhat this study addsDoctors in Norwegian hospitals reported a low level of use of all electronic medical records systemsThe systems were mainly used for reading patient data, and doctors used the systems for less than half of the tasks for which the systems were functionalAnalyses of actual use of electronic medical records provide more information than user satisfaction or functionality of such records systems
To develop methods of measuring the validity and utility of electronic patient records in general practice.
A survey of the main functional areas of a practice and use of independent criteria to measure the validity of the practice database.
A fully computerised general practice in Skipton, north Yorkshire.
The records of all registered practice patients.
Main outcome measures
Validity of the main functional areas of the practice clinical system. Measures of the completeness, accuracy, validity, and utility of the morbidity data for 15 clinical diagnoses using recognised diagnostic standards to confirm diagnoses and identify further cases. Development of a method and statistical toolkit to validate clinical databases in general practice.
The practice electronic patient records were valid, complete, and accurate for prescribed items (99.7%), consultations (98.1%), laboratory tests (100%), hospital episodes (100%), and childhood immunisations (97%). The morbidity data for 15 clinical diagnoses were complete (mean sensitivity=87%) and accurate (mean positive predictive value=96%). The presence of the Read codes for the 15 diagnoses was strongly indicative of the true presence of those conditions (mean likelihood ratio=3917). New interpretations of descriptive statistics are described that can be used to estimate both the number of true cases that are unrecorded and quantify the benefits of validating a clinical database for coded entries.
This study has developed a method and toolkit for measuring the validity and utility of general practice electronic patient records.
What is already known on this topicDelivering the performance management agenda in the NHS will depend on the availability of high quality information in general practiceRecord entries in GP systems generally consist of a mixture of text and Read coded entriesSensitivity and positive predictive value have been used to measure the completeness and accuracy of data recording in electronic patient record systemsWhat this study addsThis study has developed a standard method and toolkit for measuring the validity and utility of electronic patient record systemsThe principal innovation in this study is to consider the Read codes in the records as tests for the true presence of the associated diagnosesThis study has developed a new approach to the validation of electronic patient record systems.