Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education.
CONCLUSION: On-the-job education with feedback in clinical documentation provides a learning opportunity for medical students and is essential in order to ensure accurate, safe, succinct and timely clinical notes. PMID: 27105479 [PubMed - as supplied by publisher] (Source: Health Information Management Journal)
Source: Health Information Management Journal - April 24, 2016 Category: Health Management Tags: HIM J Source Type: research

Evaluation research studies essential to ensuring health information systems meet the needs of users, including patients.
Authors: Callen J Abstract Electronic health records and the Internet will continue to transform how information is accessed and shared. Users of health data such as health professionals, governments, policymakers, researchers and patients themselves need to be able to access the right information at the right time and be confident in the quality of that information, whether personal, aggregated or knowledge based. It is essential to evaluate information systems and applications that claim to improve information quality and access in order to provide evidence that they support healthcare delivery and impro...
Source: Health Information Management Journal - April 24, 2016 Category: Health Management Tags: HIM J Source Type: research

Healthcare in the age of open innovation - A literature review.
CONCLUSION: The healthcare sector's engagement in open innovation is limited, and it is necessary to perform further research with a focus on how open innovation can be managed in healthcare. PMID: 27105481 [PubMed - as supplied by publisher] (Source: Health Information Management Journal)
Source: Health Information Management Journal - April 24, 2016 Category: Health Management Tags: HIM J Source Type: research

Adverse events and near misses relating to information management in a hospital.
CONCLUSION: A broad spectrum of information management incidents was identified, which indicates that preventing adverse events requires the development of safe practices, especially in documentation and information transfer. PMID: 27105482 [PubMed - as supplied by publisher] (Source: Health Information Management Journal)
Source: Health Information Management Journal - April 24, 2016 Category: Health Management Tags: HIM J Source Type: research

Maternity patients' access to their electronic medical records: use and perspectives of a patient portal.
This study provides the first Australian evidence of a patient portal system, tied to an EMR, working effectively in a maternity care context. It provides new evidence that portals can deliver benefits to maternity patients in terms of providing quick and easy access to current personal and general health information and support patients in their ability to recall and prepare for appointments. PMID: 27092464 [PubMed - in process] (Source: Health Information Management Journal)
Source: Health Information Management Journal - April 21, 2016 Category: Health Management Tags: HIM J Source Type: research

Patient innovation: an analysis of patients' designs of digital technology support for everyday living with diabetes.
Authors: Kanstrup AM, Bertelsen P, Nohr C Abstract The aim of this paper is to identify characteristics of patients' contributions to innovation in health information technology (HIT). The paper outlines a theoretical definition of patient innovation and presents an analysis of four digital prototypes and 22 low-fidelity mock-ups designed by people affected by the chronic illness diabetes mellitus. Seventeen families (a total of 60 people) with one or more diabetic family members participated in design activities in a four-year research project focused on the design of digital support for everyday living w...
Source: Health Information Management Journal - April 21, 2016 Category: Health Management Tags: HIM J Source Type: research

Examination of narratives from emergency department presentations to identify road trauma, crash and injury risk factors for different age groups.
CONCLUSION: This exploratory study demonstrated the capability of information from PHREDSS to be used to support injury prevention efforts in road safety. PMID: 27092466 [PubMed - in process] (Source: Health Information Management Journal)
Source: Health Information Management Journal - April 21, 2016 Category: Health Management Tags: HIM J Source Type: research

Information technology skills and training needs of health information management professionals in Nigeria: a nationwide study.
This study examined the information technology (IT) skills, utilisation and training needs of Nigerian health information management professionals. We deployed a cross-sectional structured questionnaire to determine the IT skills and training needs of health information management professionals who have leadership roles in the nation's healthcare information systems (n=374). It was found that ownership of a computer, level of education and age were associated with knowledge and perception of IT. The vast majority of participants (98.8%) acknowledged the importance and relevance of IT in healthcare information systems and m...
Source: Health Information Management Journal - April 21, 2016 Category: Health Management Tags: HIM J Source Type: research

Encoding and verification of a computerinterpretable guideline: a case study of pressure-ulcer management.
This study examined ways to improve the accuracy of translating clinical practice guidelines (CPGs) into a computer-interpretable guideline (CIG) for pressure-ulcer management using the Shareable Active Guideline Environment (SAGE) guideline model, and aimed to verify the accuracy of the obtained CIG. The study was conducted using the following procedures: selecting CPGs, extracting rules from the selected CPGs, developing a CIG using the SAGE guideline model, and verifying the obtained CIG with test cases using an execution engine. The CIG for pressure-ulcer management was developed based on 38 rules and three algorithms ...
Source: Health Information Management Journal - April 21, 2016 Category: Health Management Tags: HIM J Source Type: research

The quality of medical record documentation and External cause of fall injury coding in a tertiary teaching hospital.
Authors: Cunningham J, Williamson DW, Robinson KM, Carroll R, Buchanan R, Paul L Abstract This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether: (i) the medical records contained sufficient information for assignment of specific External cause codes; and (ii) the most a...
Source: Health Information Management Journal - March 27, 2016 Category: Health Management Tags: HIM J Source Type: research

A process mining-based investigation of adverse events in care processes.
Authors: Caron F, Vanthienen J, Vanhaecht K, Van Limbergen E, Deweerdt J, Baesens B Abstract This paper proposes the Clinical Pathway Analysis Method (CPAM) approach that enables the extraction of valuable organisational and medical information on past clinical pathway executions from the event logs of healthcare information systems. The method deals with the complexity of real-world clinical pathways by introducing a perspective-based segmentation of the date-stamped event log. CPAM enables the clinical pathway analyst to effectively and efficiently acquire a profound insight into the clinical pathways. B...
Source: Health Information Management Journal - March 27, 2016 Category: Health Management Tags: HIM J Source Type: research

A Generic Quality Assurance Model (GQAM) for successful e-health implementation in rural hospitals in South Africa.
Authors: Ruxwana N, Herselman M, Pottas D Abstract Although e-health can potentially facilitate the management of scarce resources and improve the quality of healthcare services, implementation of e-health programs continues to fail or not fulfil expectations. A key contributor to the failure of e-health implementation in rural hospitals is poor quality management of projects. Based on a survey 35 participants from five rural hospitals in the Eastern Cape Province of South Africa, and using a qualitative case study research methodology, this article attempted to answer the question: does the adoption of qu...
Source: Health Information Management Journal - March 27, 2016 Category: Health Management Tags: HIM J Source Type: research

Standing your ground: the importance of Health Information Managers sharing what they do.
Authors: Henderson J Abstract Health information management professionals have a broad range of skills that are invaluable to the health sector. The advent of the electronic health record has provided the opportunity to aggregate patient data to answer clinical and policy questions in a systematic, timely and reproducible way. The possibility of linking datasets provides greater opportunities for answering clinical and policy questions, and Health Information Managers (HIMs) have the best skill set to inform about data quality, coding and classification, privacy, security, and medico-legal implications inv...
Source: Health Information Management Journal - January 16, 2016 Category: Health Management Tags: HIM J Source Type: research

A guide to performance management for the Health Information Manager.
Authors: Leggat SG Abstract This paper provides a summary of human resource management practices that have been identified as being associated with better outcomes in performance management. In general, essential practices include transformational leadership and a coherent program of goal setting, performance monitoring and feedback. Some Health Information Managers may feel they require training assistance to develop the necessary skills in the establishment of meaningful work performance goals for staff and the provision of useful and timely feedback. This paper provides useful information to assist Heal...
Source: Health Information Management Journal - November 19, 2015 Category: Health Management Tags: HIM J Source Type: research

Using ICD-10-AM codes to characterise hospital-acquired complications.
Authors: Michel J, Nghiem HD, Jackson TJ Abstract This paper describes the limitations of using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) to characterise patient harm in hospitals. Limitations were identified during a project to use diagnoses flagged by Victorian coders as hospital-acquired to devise a classification of 144 categories of hospital acquired diagnoses (the Classification of Hospital Acquired Diagnoses or CHADx). CHADx is a comprehensive data monitoring system designed to allow hospitals to monitor ...
Source: Health Information Management Journal - November 19, 2015 Category: Health Management Tags: HIM J Source Type: research