Abstract：
:A one-hundred percent documentation rate of diagnoses and patient data is unfeasible and should not be pursued. Therefore, a "lean documentation" of diagnoses and basic patient data was introduced. Coding is done by a clinic-specific list of diagnoses (thesaurus) with a minimum of diagnostic codes, combined with optional free text. By recording the frequency of diagnoses for two years, a thesaurus of 188 diagnostic codes was developed. Bedside coding by treating physicians reduced medical and semantic mistakes of documentation. Cooperation of the clinicians was obtained by shortening the time required for coding to less than two minutes per patient. A documentation assistant supplemented incomplete data in collaboration with the treating surgeons. During a ten-year testing period 93.7% of the hospital-specific codes of our thesaurus were required for documentation, as compared to 13.1% if the same patients were coded by ICD-9. Consequently, coding by a clinic-specific code thesaurus is quick flexible and accurate.
journal_name
Methods Inf Medjournal_title
Methods of information in medicineauthors
Schaarschmidt K,Osada N,Köpcke Wsubject
Has Abstractpub_date
1997-08-01 00:00:00pages
207-13issue
3eissn
0026-1270issn
2511-705Xpii
97030207journal_volume
36pub_type
杂志文章abstract：INTRODUCTION:This article is part of the Focus Theme of METHODS of Information in Medicine on "Managing Interoperability and Complexity in Health Systems". BACKGROUND:Data sharing and integration between the clinical research data management system and the electronic health record system remains a challenging issue. T...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME13-02-0019
更新日期：2015-01-01 00:00:00
abstract：:Informatisation of drug prescription is an important topic in medical informatics. For several years now, computerized drug databases have been implemented. Usually only a small part of the prescriptions can be stored in prescription systems because of the format of the included information; prescriptions contain esse...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：1999-03-01 00:00:00
abstract：OBJECTIVES:To evaluate split selection instability in six survival tree algorithms and its relationship with predictive error by means of a bootstrap study. METHODS:We study the following algorithms: logrank statistic with multivariate p-value adjustment without pruning (LR), Kaplan-Meier distance of survival curves (...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：2006-01-01 00:00:00
abstract：:Reliable record linkage is an essential component of the quality of population-based disease registration. Quality assessment of disease registries should, therefore, include quantitative approaches to describe the extent of record-linkage errors. The homonym and synonym rates have been proposed for this purpose. The ...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：1996-03-01 00:00:00
abstract：:Artificial neural networks (ANNs) are compared to standard statistical methods for outcome prediction in biomedical problems. A general method for using genetic algorithms to "evolve" ANN architecture (EANN) is presented. Accuracy of logistic regression, a fully interconnected ANN, and an EANN for predicting depressio...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：1998-09-01 00:00:00
abstract：OBJECTIVES:The log-binomial model is recommended for calculating the prevalence ratio in cross-sectional studies with binary outcomes. However, convergence problems may occur as this model is numerically unstable. If this happens, the Poisson model should be used, but the Poisson model variance needs to be adjusted. He...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.1160/me0416
更新日期：2007-01-01 00:00:00
abstract：OBJECTIVES:Hospital information systems (HIS) are the hospital's nervous system. The HIS are mostly grown over several years, dedicated to specific needs and comprise individual workarounds. Changes to such complex systems may cause a variety of differ-ent negative side-effects. In order to understand the nature of inc...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME9220
更新日期：2009-01-01 00:00:00
abstract：OBJECTIVE:To explain the common conformance and interoperability testing requirements of eHealth applications through two case studies; one using a prominent eHealth messaging standard, namely HL7 v3 [1], and the other using Integrating the Healthcare Enterprise (IHE) [2] Profiles and to describe how these testing requ...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME09-02-0022
更新日期：2010-01-01 00:00:00
abstract：BACKGROUND:The barbell squat is a popularly used lower limb rehabilitation exercise. It is also an integral exercise in injury risk screening protocols. To date athlete/patient technique has been assessed using expensive laboratory equipment or subjective clinical judgement; both of which are not without shortcomings. ...
journal_title：Methods of information in medicine
pub_type： 临床试验,杂志文章
doi：10.3414/ME16-01-0141
更新日期：2017-10-26 00:00:00
abstract：OBJECTIVES:Describe how the HL7 Clinical Document Architecture (CDA), a foundational standard in US Meaningful Use, contributes to a "big data, incrementally structured" interoperability strategy, whereby data structured incrementally gets large amounts of data flowing faster. We present cases showing how this approach...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME14-01-0030
更新日期：2015-01-01 00:00:00
abstract：OBJECTIVE:The objective of this study is to develop a solution to preserve security and privacy in a healthcare environment where health-sensitive information will be accessed by many parties and stored in various distributed databases. The solution should maintain anonymous medical records and it should be able to lin...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/me9116
更新日期：2008-01-01 00:00:00
abstract：OBJECTIVES:The healthcare sector is facing an enormous acceleration due to the emergence of new knowledge, drugs, devices and diseases. Professional competence, continuing education, service excellence and patient benefits can be facilitated by the developments in information and computer technology--computer literacy ...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：2006-01-01 00:00:00
abstract：OBJECTIVES:The International Medical Informatics Association (IMIA) today is an inclusive organization that represents the medical and health informatics world through its multiple member countries as well as affiliate, corporate and academic institutions, plus working groups and regions. The IMIA leadership deemed thi...
journal_title：Methods of information in medicine
pub_type： 社论
doi：
更新日期：2006-01-01 00:00:00
abstract：OBJECTIVES:The exchange of medical data from research and clinical routine across institutional borders is essential to establish an integrated healthcare platform. In this project we want to realize the standardized exchange of medical data between different healthcare institutions to implement an integrated and inter...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：2006-01-01 00:00:00
abstract：OBJECTIVE:Record linkage of patient data originating from various data sources and record linkage for checking uniqueness of patient registration are common tasks for every cancer registry. In Austria, there is no unique person identifier in use in the medical system. Hence, it was necessary and the goal of this work t...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：2005-01-01 00:00:00
abstract：INTRODUCTION:This article is part of the Focus Theme of Methods of Information in Medicine on "Biosignal Interpretation: Advanced Methods for Studying Cardiovascular and Respiratory Systems". OBJECTIVES:The aim of this study is to assess the reliability of the estimated Nocturnal Heart Rate (HR), recorded through a be...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME13-02-0053
更新日期：2014-01-01 00:00:00
abstract：BACKGROUND:The single leg squat (SLS) is a common lower limb rehabilitation exercise. It is also frequently used as an evaluative exercise to screen for an increased risk of lower limb injury. To date athlete / patient SLS technique has been assessed using expensive laboratory equipment or subjective clinical judgement...
journal_title：Methods of information in medicine
pub_type： 临床试验,杂志文章
doi：10.3414/ME16-02-0002
更新日期：2017-03-23 00:00:00
abstract：BACKGROUND:The central control of the autonomic nervous system (ANS) and the complex interplay of its components can be described by a functional integrated mode - the central autonomic network (CAN). CAN represents the integrated functioning and interaction between the central nervous system (CNS) and ANS (parasympath...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME17-02-0002
更新日期：2018-05-01 00:00:00
abstract：OBJECTIVE:Record linkage may create powerful datasets with which investigators can conduct comparative effectiveness studies evaluating the impact of tests or interventions on health. All linkages of health care data files to date have used protected health information (PHI) in their linkage variables. A technique to l...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME14-01-0093
更新日期：2015-01-01 00:00:00
abstract：:A Bayesian decision support system was developed for the diagnosis of rheumatic disorders. Knowledge in this system is represented as evidential weights of findings. Simple weights were calculated as the logarithm of likelihood ratios on the basis of 1,000 consecutive patients from a rheumatological clinic. The effect...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：1991-08-01 00:00:00
abstract：:Often in drug trials only the objective, or the subjective responses of the subjects are investigated, depending on the kind of drug. It is, however, desirable to check both the objective and the subjective responses in every drug trial. The investigation of the objective symptoms which is especially necessary in psyc...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：1963-01-01 00:00:00
abstract：OBJECTIVES:Biomedical ontologies exist to serve integration of clinical and experimental data, and it is critical to their success that they be put to widespread use in the annotation of data. How, then, can ontologies achieve the sort of user-friendliness, reliability, cost-effectiveness, and breadth of coverage that ...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME9302
更新日期：2010-01-01 00:00:00
abstract：:Acute appendicitis is the most common cause of acute abdomen requiring surgical intervention. The clinical diagnosis of acute appendicitis is not always easy due to variable symptomatology, particularly at the onset. The contributions of history-taking and physical examination in the diagnosis of acute appendicitis wa...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：1994-05-01 00:00:00
abstract：OBJECTIVES:As millions of consumers perform health information retrieval online, the mismatch between their terminology and the terminologies of the information sources could become a major barrier to successful retrievals. To address this problem, we studied the characteristics of consumer terminology for health infor...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：2002-01-01 00:00:00
abstract：OBJECTIVE:The purpose of this study was to investigate the effects of hybrid environments (i.e. where part of the patient record is paper-based and part of it is electronic) upon aspects of novice nurse information seeking (i.e. amount of information accessed, choice of key information sources, type of information and ...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：10.3414/ME9222
更新日期：2009-01-01 00:00:00
abstract：:In more and more medical settings, physicians have less and less time to be effective communicators. To be effective, they need accurate, current information about their patients. Tailored health communications can facilitate positive patient-provider communications and foster behavioral changes conducive to health. T...
journal_title：Methods of information in medicine
pub_type： 杂志文章,评审
doi：
更新日期：1998-06-01 00:00:00
abstract：:In this paper the design and implementation of a decision support system for diabetes care is examined from an ethical perspective. It is noted that the system creates potential for enhancing the realization of the principle of autonomy through improved information to patients and participation by patients. However, t...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：1999-12-01 00:00:00
abstract：:Appropriateness and necessity research of various procedures in medicine may be the most complex field of innovation in healthcare and technology assessment. Nevertheless, the appropriateness of the indication of any medical intervention is probably more important than the outcome since even ideal quality components o...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：2000-08-01 00:00:00
abstract：OBJECTIVES:Data collected within the German nosocomial infection surveillance system KISS are recommended as reference data for judging nosocomial infection rates in German intensive care units (ICUs). It is unknown whether the KISS data tend to under- or overestimate the true infection incidence rates. In this article...
journal_title：Methods of information in medicine
pub_type： 杂志文章,多中心研究
doi：
更新日期：2006-01-01 00:00:00
abstract：:A few years ago, a new method of survival analysis, denoted period analysis, has been developed to derive more up-to-date estimates of long-term survival rates of cancer patients, but this method has rarely been applied so far. Using empirical examples from the Saarland Cancer Registry, we illustrate how seriously tra...
journal_title：Methods of information in medicine
pub_type： 杂志文章
doi：
更新日期：2001-07-01 00:00:00
