This clinical review document provides an overview of health informatics and discusses key concepts around clinical information including how it is captured, represented, interpreted, stored, and used. It examines these issues through the example of a clinical encounter between Dr. McKay and patient Ms. Smith. The document also discusses where clinical information comes from, how to assess its quality, and the various costs associated with capturing and processing information.
This document summarizes key concepts around using clinical data and informatics tools to improve healthcare services. It discusses how data from multiple sources can be linked and analyzed to provide intelligence to decision-makers. However, issues around data protection, privacy and ensuring data is used appropriately must be addressed. Effective presentation of data is important so clinicians view it as valid and are motivated to change practices. Feedback of performance data can improve quality when done constructively and by considering the local context.
Ms. Amulya Patel uses the internet to research her risk of breast cancer after her mother's diagnosis. She finds many resources online, including patient portals and medical literature, but may have difficulty interpreting information without professional help. The document describes how electronic tools can provide initial information for health issues, but a consultation is still beneficial for personalized risk assessment and advice. Online information prompted Ms. Patel to ask her family about their cancer history, finding a strong familial link, so she sought a genetics expert's opinion. While the internet can satisfy some health questions, patients may need a doctor's expertise to properly interpret data.
This document provides definitions for various terms related to health informatics. It defines terms such as algorithm, bioinformatics, clinical coding system, clinical data system, clinical decision tool, communication, database, electronic health record, and medical knowledge. The definitions cover topics such as the use of informatics methods and technologies in research, clinical practice, public health, and consumer health contexts.
This document provides definitions for various terms related to health informatics. It defines terms such as algorithm, bioinformatics, clinical coding system, clinical data system, clinical decision tool, communication, database, electronic health record, and medical knowledge. The definitions cover topics such as the use of informatics methods and technologies in clinical care, research, public health, and consumer health contexts.
This document summarizes an article about how clinical informatics tools can help make patient consultations more efficient. It discusses how computers can help clinicians obtain relevant patient information, assess the patient's status, and take effective management steps. It also explains how recording consultation data can produce useful information to improve local healthcare services and inform broader health system policies. The document provides a flow chart outlining the acute asthma management process in emergency departments for children over 5 years old.
1) The article discusses health informatics and how it helps doctors make better decisions by improving how patient data and medical knowledge is captured, processed, communicated and applied.
2) It focuses on how information is handled during routine clinical tasks like consultations and covers broader issues related to things like medical record keeping, communicating with colleagues and patients, and keeping clinical knowledge up to date.
3) It explains the differences between actual information, representations of that information, and how individuals may interpret it, noting that information is best captured and represented in a way that helps both human and computer users find and interpret it.
How computers can help to share understanding with patientseduardo guagliardi
This document provides an overview of how computers and interactive health applications can help doctors share information and clinical understanding with patients. It discusses the case of Ms. Patel, who met with her doctor and genetics clinic team to discuss her family history of breast cancer and 30% lifetime risk of also developing breast cancer. The team created a genogram to visualize her family history and risks. The document then discusses the benefits of interactive tools for improving patient understanding, reducing uncertainty, and better supporting patients. It provides some examples of how images, videos and other multimedia can help explain clinical information to patients during consultations.
This document summarizes key concepts around using clinical data and informatics tools to improve healthcare services. It discusses how data from multiple sources can be linked and analyzed to provide intelligence to decision-makers. However, issues around data protection, privacy and ensuring data is used appropriately must be addressed. Effective presentation of data is important so clinicians view it as valid and are motivated to change practices. Feedback of performance data can improve quality when done constructively and by considering the local context.
This document summarizes key concepts around using clinical data and informatics tools to improve healthcare services. It discusses how data from multiple sources can be linked and analyzed to provide intelligence to decision-makers. However, issues around data protection, privacy and ensuring data is used appropriately must be addressed. Effective presentation of data is important so clinicians view it as valid and are motivated to change practices. Feedback of performance data can improve quality when done constructively and by considering the local context.
Ms. Amulya Patel uses the internet to research her risk of breast cancer after her mother's diagnosis. She finds many resources online, including patient portals and medical literature, but may have difficulty interpreting information without professional help. The document describes how electronic tools can provide initial information for health issues, but a consultation is still beneficial for personalized risk assessment and advice. Online information prompted Ms. Patel to ask her family about their cancer history, finding a strong familial link, so she sought a genetics expert's opinion. While the internet can satisfy some health questions, patients may need a doctor's expertise to properly interpret data.
This document provides definitions for various terms related to health informatics. It defines terms such as algorithm, bioinformatics, clinical coding system, clinical data system, clinical decision tool, communication, database, electronic health record, and medical knowledge. The definitions cover topics such as the use of informatics methods and technologies in research, clinical practice, public health, and consumer health contexts.
This document provides definitions for various terms related to health informatics. It defines terms such as algorithm, bioinformatics, clinical coding system, clinical data system, clinical decision tool, communication, database, electronic health record, and medical knowledge. The definitions cover topics such as the use of informatics methods and technologies in clinical care, research, public health, and consumer health contexts.
This document summarizes an article about how clinical informatics tools can help make patient consultations more efficient. It discusses how computers can help clinicians obtain relevant patient information, assess the patient's status, and take effective management steps. It also explains how recording consultation data can produce useful information to improve local healthcare services and inform broader health system policies. The document provides a flow chart outlining the acute asthma management process in emergency departments for children over 5 years old.
1) The article discusses health informatics and how it helps doctors make better decisions by improving how patient data and medical knowledge is captured, processed, communicated and applied.
2) It focuses on how information is handled during routine clinical tasks like consultations and covers broader issues related to things like medical record keeping, communicating with colleagues and patients, and keeping clinical knowledge up to date.
3) It explains the differences between actual information, representations of that information, and how individuals may interpret it, noting that information is best captured and represented in a way that helps both human and computer users find and interpret it.
How computers can help to share understanding with patientseduardo guagliardi
This document provides an overview of how computers and interactive health applications can help doctors share information and clinical understanding with patients. It discusses the case of Ms. Patel, who met with her doctor and genetics clinic team to discuss her family history of breast cancer and 30% lifetime risk of also developing breast cancer. The team created a genogram to visualize her family history and risks. The document then discusses the benefits of interactive tools for improving patient understanding, reducing uncertainty, and better supporting patients. It provides some examples of how images, videos and other multimedia can help explain clinical information to patients during consultations.
This document summarizes key concepts around using clinical data and informatics tools to improve healthcare services. It discusses how data from multiple sources can be linked and analyzed to provide intelligence to decision-makers. However, issues around data protection, privacy and ensuring data is used appropriately must be addressed. Effective presentation of data is important so clinicians view it as valid and are motivated to change practices. Feedback of performance data can improve quality when done constructively and by considering the local context.
1) The document discusses the promise and potential perils of eHealth technologies like remote monitoring devices, virtual assistants, and personalized health records.
2) Factors driving eHealth include patient demand for convenient access to information, the ability to link separate health services, and using technology to address issues like staff shortages.
3) Potential benefits include improved patient information and choice, better communication between providers, and links to vetted external health resources. However, issues around privacy and control of personal data still need solutions.
The Indian Parliament passed the Companies Bill 2013, replacing the previous Companies Act of 1956. The new law aims to modernize corporate regulation in India and promote business-friendly initiatives. It provides for greater transparency, accountability, and protection of minority shareholders and investors. Some key changes include allowing more members in private companies, introducing one-person companies, mandatory CSR spending for large companies, restrictions on related party transactions and loans to directors, and establishing a new National Company Law Tribunal to handle corporate matters instead of the High Court. The new law is expected to facilitate business while improving governance.
1. Ms Smith developed symptomatic renal impairment that may have been avoided if her underlying medical issues were properly diagnosed and treated earlier at multiple points in her care.
2. Ensuring appropriate follow-up and continuity of care between primary care physicians and specialists can help reduce risks for patients with chronic conditions like Ms Smith.
3. Integrating medical records electronically across different parts of a healthcare system can improve information sharing, guide treatment according to best practices, and ultimately enhance patient outcomes.
How decision support tools help define clinical problemseduardo guagliardi
1) The document discusses using informatics resources like decision support tools to consider issues beyond a patient's presenting problem during a clinical consultation, including management of continuing problems, opportunistic health promotion, and modification of help-seeking behaviors.
2) It provides an example of how these tools could help in the consultation of a patient, Mr. Evans, who presented with headaches and sleep issues but was also found to have high blood pressure and undisclosed alcohol use, which are relevant to understanding his overall health situation and treating his depression.
3) The document examines how electronic prompts can help bring hidden issues to light and make both doctors and patients aware of all factors that could impact the patient's health, though clinical judgement
This document summarizes key aspects of clinical review and use of health informatics in patient assessment. It discusses 1) using open questions rather than closed questions to understand the patient's reason for visiting, 2) considering symptoms and non-verbal cues to form an initial hypothesis, 3) gathering a medical history over time to understand recurring issues, 4) reviewing records such as laboratory results, prescriptions, and family history to inform the diagnosis, and 5) the importance of coding clinical data for storage and communication between healthcare providers and systems.
Ms. Patel uses the internet to research her risk of breast cancer after her mother's diagnosis. The document discusses how eHealth tools allow people to research health issues without a doctor's consultation. It describes search engines, patient portals, and ways to access medical literature. Risk is often described in complex ways, so many people prefer professional help interpreting information. Guidelines suggest when to see a genetics specialist based on family cancer history.
This document summarizes how clinical information can help doctors understand patients and their health issues. It provides examples of how a doctor uses a patient's medical history, including prior visits, prescriptions, lab results, and family history to inform their assessment of the patient's current issues. The document also contrasts experienced doctors' hypothetico-deductive approach to less experienced doctors' more exhaustive checklist method. Overall, it discusses how electronic medical records can provide doctors important context to help identify health problems and guide their consultation with patients.
1) The document discusses the promise and potential perils of eHealth technologies like remote monitoring devices, virtual assistants, and personalized health records.
2) Factors driving eHealth include patient demand for convenient access to information, the ability to link separate health services, and using technology to address staffing shortages. However, eHealth may also shift costs to patients and change the role of healthcare providers.
3) Potential benefits of eHealth include improved patient information and choice, better communication between providers, and links to vetted external health resources. However, ensuring privacy and appropriate access to personal health data is also discussed.
This document discusses how essays are classified based on style and subject matter. Essays can be classified into formal or informal styles based on how they are written. They can also be classified based on their subject matter into categories like character sketches, descriptive essays, philosophical essays, editorials, critical essays, scientific essays, semi-narrative essays, and biographical essays based on their content and focus. Effective essays express a vital point, widen the reader's intellectual range, reveal the author's personality, and have an appropriately beautiful style with elements like humor or imagination.
How decision support tools help define clinical problemseduardo guagliardi
1) The document discusses how decision support tools can help doctors consider issues beyond a patient's presenting problem during a consultation, including management of ongoing medical problems, opportunistic health promotion, and modifying patient help-seeking behaviors.
2) It provides an example consultation with patient Mr. Evans, who presented with headaches and sleep issues, but is also found to have high blood pressure and an alcohol problem complicating his known diabetes.
3) The document examines how electronic prompts can help bring hidden health issues to light to provide more effective treatment that addresses underlying problems driving a patient's symptoms.
How computers can help to share understanding with patientseduardo guagliardi
This document provides an overview of how computers and interactive health applications can help doctors share information and clinical understanding with patients. It discusses the case of Ms. Patel, who met with her doctor and genetics clinic team to discuss her family history of breast cancer and 30% lifetime risk of also developing breast cancer. The team created a genogram using software to visualize her family history and risk factors. The document then discusses the benefits of interactive tools for improving patient understanding, reducing uncertainty, and supporting patients. It also notes challenges in using these tools during medical consultations due to time constraints.
1. Ms Smith developed symptomatic renal impairment that may have been avoided if her underlying medical issues were properly diagnosed and treated earlier at multiple points in her care.
2. Ensuring appropriate follow-up and continuity of care between primary and secondary healthcare providers is challenging but important to reduce risks to patients.
3. The integration of clinical records and guidelines across healthcare locations and providers could help improve diagnosis, investigation, referral and follow-up to reduce risks to patients like Ms Smith.
The document discusses integrating genomics data and evidence-based medicine into electronic health records (EHRs) for precision healthcare. It notes the gap between what is known and what is done in healthcare. Integrating genomics could help do the right thing for each patient through pharmacogenomics. However, challenges include representing huge volumes of molecular data in a usable way in EHRs. A three step approach is proposed: 1) get genomic data into EHRs in a structured format, 2) use that data for clinical decision support, 3) evaluate outcomes and continually improve the system.
Health Care Processes and Decision Making_lecture 1_slidesCMDLearning
The document discusses the classic paradigm of the clinical process. It describes the elements of the classic paradigm, which assumes a single patient interacts with a single clinician to address a single problem during a single visit. It also examines different types of information clinicians use and how this information is organized. The document outlines the steps in the classic clinical process, including gathering data, analyzing findings, making a diagnosis, and communicating the treatment plan.
The document summarizes the author's journey working with healthcare data and machine learning to improve clinical outcomes. It discusses challenges in translating data insights into action, and the need for collaboration between data scientists and medical professionals like nurses. Nurses understand healthcare interventions and how to improve patient outcomes, while data scientists create models but lack clinical expertise. The author provides their toolbox for finding opportunities and communicating skills to facilitate collaborations that leverage both data science and clinical knowledge.
The Dual Nature of InformaticsInformatics can be used for impr.docxhe45mcurnow
The document discusses the dual nature of informatics, which refers to how informatics can improve health outcomes for individual patients through tools like EHRs and CDS at the point of care, and also for groups of patients through data warehousing and mining of patient information in EHRs. It provides a scenario about a patient, Mrs. Jones, presenting with dizzy spells and nausea, and prompts the reader to consider what information should be collected from Mrs. Jones and how it could help her care and be aggregated to help other similar patients.
The document summarizes a research article about clinical judgment in nursing. It discusses how clinical judgment is influenced by a nurse's background, experience with patients, and the context of each situation. It also explores the role of intuition and how nurses develop their clinical reasoning abilities over time. The document reviews nearly 200 studies on clinical judgment and identifies that a nurse's inferences are more influenced by what they bring to a situation than objective data alone. Experience with individual patients and reflection are important for developing strong clinical judgment.
1) The document discusses the promise and potential perils of eHealth technologies like remote monitoring devices, virtual assistants, and personalized health records.
2) Factors driving eHealth include patient demand for convenient access to information, the ability to link separate health services, and using technology to address issues like staff shortages.
3) Potential benefits include improved patient information and choice, better communication between providers, and links to vetted external health resources. However, issues around privacy and control of personal data still need solutions.
The Indian Parliament passed the Companies Bill 2013, replacing the previous Companies Act of 1956. The new law aims to modernize corporate regulation in India and promote business-friendly initiatives. It provides for greater transparency, accountability, and protection of minority shareholders and investors. Some key changes include allowing more members in private companies, introducing one-person companies, mandatory CSR spending for large companies, restrictions on related party transactions and loans to directors, and establishing a new National Company Law Tribunal to handle corporate matters instead of the High Court. The new law is expected to facilitate business while improving governance.
1. Ms Smith developed symptomatic renal impairment that may have been avoided if her underlying medical issues were properly diagnosed and treated earlier at multiple points in her care.
2. Ensuring appropriate follow-up and continuity of care between primary care physicians and specialists can help reduce risks for patients with chronic conditions like Ms Smith.
3. Integrating medical records electronically across different parts of a healthcare system can improve information sharing, guide treatment according to best practices, and ultimately enhance patient outcomes.
How decision support tools help define clinical problemseduardo guagliardi
1) The document discusses using informatics resources like decision support tools to consider issues beyond a patient's presenting problem during a clinical consultation, including management of continuing problems, opportunistic health promotion, and modification of help-seeking behaviors.
2) It provides an example of how these tools could help in the consultation of a patient, Mr. Evans, who presented with headaches and sleep issues but was also found to have high blood pressure and undisclosed alcohol use, which are relevant to understanding his overall health situation and treating his depression.
3) The document examines how electronic prompts can help bring hidden issues to light and make both doctors and patients aware of all factors that could impact the patient's health, though clinical judgement
This document summarizes key aspects of clinical review and use of health informatics in patient assessment. It discusses 1) using open questions rather than closed questions to understand the patient's reason for visiting, 2) considering symptoms and non-verbal cues to form an initial hypothesis, 3) gathering a medical history over time to understand recurring issues, 4) reviewing records such as laboratory results, prescriptions, and family history to inform the diagnosis, and 5) the importance of coding clinical data for storage and communication between healthcare providers and systems.
Ms. Patel uses the internet to research her risk of breast cancer after her mother's diagnosis. The document discusses how eHealth tools allow people to research health issues without a doctor's consultation. It describes search engines, patient portals, and ways to access medical literature. Risk is often described in complex ways, so many people prefer professional help interpreting information. Guidelines suggest when to see a genetics specialist based on family cancer history.
This document summarizes how clinical information can help doctors understand patients and their health issues. It provides examples of how a doctor uses a patient's medical history, including prior visits, prescriptions, lab results, and family history to inform their assessment of the patient's current issues. The document also contrasts experienced doctors' hypothetico-deductive approach to less experienced doctors' more exhaustive checklist method. Overall, it discusses how electronic medical records can provide doctors important context to help identify health problems and guide their consultation with patients.
1) The document discusses the promise and potential perils of eHealth technologies like remote monitoring devices, virtual assistants, and personalized health records.
2) Factors driving eHealth include patient demand for convenient access to information, the ability to link separate health services, and using technology to address staffing shortages. However, eHealth may also shift costs to patients and change the role of healthcare providers.
3) Potential benefits of eHealth include improved patient information and choice, better communication between providers, and links to vetted external health resources. However, ensuring privacy and appropriate access to personal health data is also discussed.
This document discusses how essays are classified based on style and subject matter. Essays can be classified into formal or informal styles based on how they are written. They can also be classified based on their subject matter into categories like character sketches, descriptive essays, philosophical essays, editorials, critical essays, scientific essays, semi-narrative essays, and biographical essays based on their content and focus. Effective essays express a vital point, widen the reader's intellectual range, reveal the author's personality, and have an appropriately beautiful style with elements like humor or imagination.
How decision support tools help define clinical problemseduardo guagliardi
1) The document discusses how decision support tools can help doctors consider issues beyond a patient's presenting problem during a consultation, including management of ongoing medical problems, opportunistic health promotion, and modifying patient help-seeking behaviors.
2) It provides an example consultation with patient Mr. Evans, who presented with headaches and sleep issues, but is also found to have high blood pressure and an alcohol problem complicating his known diabetes.
3) The document examines how electronic prompts can help bring hidden health issues to light to provide more effective treatment that addresses underlying problems driving a patient's symptoms.
How computers can help to share understanding with patientseduardo guagliardi
This document provides an overview of how computers and interactive health applications can help doctors share information and clinical understanding with patients. It discusses the case of Ms. Patel, who met with her doctor and genetics clinic team to discuss her family history of breast cancer and 30% lifetime risk of also developing breast cancer. The team created a genogram using software to visualize her family history and risk factors. The document then discusses the benefits of interactive tools for improving patient understanding, reducing uncertainty, and supporting patients. It also notes challenges in using these tools during medical consultations due to time constraints.
1. Ms Smith developed symptomatic renal impairment that may have been avoided if her underlying medical issues were properly diagnosed and treated earlier at multiple points in her care.
2. Ensuring appropriate follow-up and continuity of care between primary and secondary healthcare providers is challenging but important to reduce risks to patients.
3. The integration of clinical records and guidelines across healthcare locations and providers could help improve diagnosis, investigation, referral and follow-up to reduce risks to patients like Ms Smith.
The document discusses integrating genomics data and evidence-based medicine into electronic health records (EHRs) for precision healthcare. It notes the gap between what is known and what is done in healthcare. Integrating genomics could help do the right thing for each patient through pharmacogenomics. However, challenges include representing huge volumes of molecular data in a usable way in EHRs. A three step approach is proposed: 1) get genomic data into EHRs in a structured format, 2) use that data for clinical decision support, 3) evaluate outcomes and continually improve the system.
Health Care Processes and Decision Making_lecture 1_slidesCMDLearning
The document discusses the classic paradigm of the clinical process. It describes the elements of the classic paradigm, which assumes a single patient interacts with a single clinician to address a single problem during a single visit. It also examines different types of information clinicians use and how this information is organized. The document outlines the steps in the classic clinical process, including gathering data, analyzing findings, making a diagnosis, and communicating the treatment plan.
The document summarizes the author's journey working with healthcare data and machine learning to improve clinical outcomes. It discusses challenges in translating data insights into action, and the need for collaboration between data scientists and medical professionals like nurses. Nurses understand healthcare interventions and how to improve patient outcomes, while data scientists create models but lack clinical expertise. The author provides their toolbox for finding opportunities and communicating skills to facilitate collaborations that leverage both data science and clinical knowledge.
The Dual Nature of InformaticsInformatics can be used for impr.docxhe45mcurnow
The document discusses the dual nature of informatics, which refers to how informatics can improve health outcomes for individual patients through tools like EHRs and CDS at the point of care, and also for groups of patients through data warehousing and mining of patient information in EHRs. It provides a scenario about a patient, Mrs. Jones, presenting with dizzy spells and nausea, and prompts the reader to consider what information should be collected from Mrs. Jones and how it could help her care and be aggregated to help other similar patients.
The document summarizes a research article about clinical judgment in nursing. It discusses how clinical judgment is influenced by a nurse's background, experience with patients, and the context of each situation. It also explores the role of intuition and how nurses develop their clinical reasoning abilities over time. The document reviews nearly 200 studies on clinical judgment and identifies that a nurse's inferences are more influenced by what they bring to a situation than objective data alone. Experience with individual patients and reflection are important for developing strong clinical judgment.
What if we never agree on a common health information model?Koray Atalag
In this talk I will touch on some hard problems in health informatics around working with structured data and why we can’t link and reuse them with ease. The essence of the problem is that, while clinicians can perfectly understand each other, IT systems can’t. Traditional IT requires formally defined common terminology, meta-data, data and process definitions. While Medicine is mostly accepted as positive science, yet the great variation in the body of knowledge and practice is often seen as ‘Art’. Ignoring this bit, IT people tend to develop all-inclusive common information models (almost always too complex to implement) and expect everybody adhere to that. Clinicians love to do things a bit differently and of course don’t buy into that! Maybe they are right! Maybe we don’t have to agree on a uniform model at all. This is the basic assumption of the openEHR methodology which I will describe by giving clinical examples. The main premise of this approach is to effectively separate tasks of healthcare and technical professionals. Clinicians can easily define their information needs as they like using visual tools – called Archetypes which are essentially maximal data sets. These computable artefacts, built using a well defined set of technical building blocks, are then fed into the technical environment to integrate data or develop software. Lastly the free web based openEHR Clinical Knowledge Manager portal provides collaborative Archetype development and ensures semantic consistency among different models.
Clinical Decision-Making And Clinical Judgment AnalysisCasey Hudson
Clinical decision-making and clinical judgment are closely linked but distinct concepts. Clinical judgment involves assessing alternatives, while clinical decision-making is choosing between alternatives. Making the best choice requires a rationale informed by asking questions to gather relevant information. Clinical reasoning is defined as the process nurses use to collect data, understand patient situations, plan and provide interventions, evaluate outcomes, and learn from experience.
This document discusses the role of health sciences librarians in evidence-based practice and outlines several key points:
1) It defines evidence-based practice and describes the evolution of evidence-based medicine, noting its emergence as a new paradigm for medical practice.
2) It outlines the key steps in the evidence-based practice process, including question framing using structures like PICO, identifying different levels of evidence, critical appraisal of sources, and searching for and screening systematic reviews.
3) It discusses the role of librarians in supporting evidence-based practice through skills like developing comprehensive search strategies, selecting appropriate sources, and keeping detailed records to allow searches to be replicated. Librarians can teach
This document discusses the importance of health literacy and provides tips for improving health communications.
Health literacy is defined as a person's ability to obtain, process, and understand basic health information. Education level is the best predictor of health status, and those with low health literacy often have poor health outcomes. The document outlines strategies health lawyers can use to incorporate health literacy into their work, such as using clear language and design in documents and ensuring clients are trained to effectively communicate with patients. Tips for improving health communications include structuring all materials for low literacy, using universal precautions, emphasizing in-person conversations, employing user-focused design, and carefully explaining risks and statistics. An example process for creating a health-literate
Evidence-based practice (EBP) aims to help healthcare organizations meet the Quadruple Aim of improving patient experience, population health, costs, and provider work life. EBP integrates research evidence, clinical expertise, and patient values into decision-making. It can help enhance patient experience through better care, improve population health by generating insight into health characteristics, reduce costs by improving value and seamless data tracking, and improve provider work life by identifying stressors and easing burdens. Overall, EBP provides an approach for organizations to consider when aiming to achieve the balanced objectives of the Quadruple Aim.
Curso de introdução à informática em saúde apresentação ao colegiadoeduardo guagliardi
Este documento descreve um curso introdutório sobre informática em saúde ministrado por Renato Sabbatini na UNIPLAC em 2012. O curso será online e assíncrono, dividido em 10 módulos sobre diversos tópicos como prontuário eletrônico, telemedicina e sistemas de informação hospitalar. Os alunos serão avaliados por questionários, exercícios e discussões em fórum, podendo obter certificado se alcançarem nota mínima de 70%.
O documento discute a importância do prontuário médico para proteger médicos éticos, ameaçar aqueles sem escrúpulos, e proteger contra reclamações de pacientes insatisfeitos.
1) Doctors must continue learning after medical school to keep up with changing knowledge, but traditional continuing education methods may not optimally impact clinical practice.
2) Workplace learning, where doctors learn by answering clinical questions that arise during patient care, is more effective for retaining knowledge and applying it.
3) However, workplace learning faces barriers like lack of time and clear questioning skills. Prioritizing urgent questions and using efficient knowledge resources can help address these barriers.
Directory information is vital for navigating healthcare services but is often inadequate. It provides contact details of local services, specialists' preferences, and how to access tests and referrals. However, directory information is difficult to maintain as it is locally specific and changes frequently. While new technologies may help, current solutions are fragmented without a consistent format or centralized responsibility. Improving the collection and use of accurate, up-to-date directory information could support clinicians and reduce patient frustrations when navigating the healthcare system.
Este documento discute o prontuário eletrônico do paciente (PEP) na assistência, informação e conhecimento médico. Ele apresenta o PEP e sua importância, discute padrões de registro e transmissão de dados em saúde, e examina aplicações do PEP em diversas áreas como educação, pesquisa, telemedicina e gestão da qualidade. O documento é direcionado a profissionais de saúde e tem como objetivo difundir os conceitos e benefícios do PEP.
O documento discute as diferenças entre depressão unipolar e bipolar, enfatizando que: 1) a depressão é frequentemente a apresentação inicial do transtorno bipolar, mas é erroneamente diagnosticada como unipolar; 2) os bipolares passam mais tempo deprimidos do que maníacos/hipomaníacos; 3) vários sintomas e características sugerem um diagnóstico de bipolaridade ao invés de unipolar.
O documento discute a importância da informática na saúde e propõe várias iniciativas de colaboração entre a Sociedade Brasileira de Informática em Saúde (SBIS) e a Uniplac, incluindo cursos online sobre o tema para alunos e professores e a exibição de webconferências gravadas.
Este documento apresenta os resultados de uma pesquisa realizada pelo Conselho Regional de Medicina do Estado de São Paulo (Cremesp) para avaliar 85 Centros de Atenção Psicossocial (CAPS) no estado de São Paulo, representando cerca de 40% da rede instalada. A pesquisa identificou lacunas no funcionamento dos CAPS, como falta de profissionais, ausência de atendimento médico e retaguarda para emergências. As conclusões apontam para a necessidade de aprimorar a supervisão, capacitação de equipes, atividades comunitárias e
Este documento discute como os coordenadores dos Centros de Atenção Psicossocial Infantojuvenil (CAPSi) percebem o valor e a utilidade dos prontuários de pacientes. Os coordenadores veem os prontuários como valiosas ferramentas de trabalho, importantes para intervenção clínica e acompanhamento. No entanto, eles não percebem qual seria a utilidade dos prontuários para os próprios pacientes.
This document summarizes an article about how clinical informatics tools can help make patient consultations more efficient. It provides guidelines for assessing the severity of asthma exacerbations in children and outlines the steps for acute asthma management in an emergency department. Recording clinical data from patient encounters enables clinicians to better understand local service needs, compare performance to other health systems, and continuously improve care over time.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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What is health information
1. Clinical review
ABC of health informatics
What is health information? This is the first in a series of 12 articles
A glossary of terms is available on bmj.com
Jeremy C Wyatt, Frank Sullivan
Information is an ethereal commodity. One definition describes
it as the data and knowledge that intelligent systems (human
and artificial) use to support their decisions. Health informatics
helps doctors with their decisions and actions, and improves
patient outcomes by making better use of information—making
more efficient the way patient data and medical knowledge is
captured, processed, communicated, and applied. These
challenges have become more important since the internet
made access to medical information easier for patients.
This ABC series focuses on information handling during
routine clinical tasks, using scenarios based on Pendleton’s
seven-stage consultation model (see box opposite). The articles
JOHN GREIM/SPL
cover wider issues arising from, and extending beyond, the
immediate consultation (see box below). Questions on clinical
information that often arise in clinical and reflective practice are
dealt with, but discussion of specific computer systems is
avoided (a glossary of terms appears on bmj.com, and other
glossaries are listed in the box at the end of this article).
Some questions on clinical information Pendleton’s consultation model, adapted for ABC series
Medical record keeping x Discover the reason for the patient’s attendance
x What records to keep? x Consider other problems
x In what format? x Achieve a shared understanding of the problems with the patient
x What data to enter, and how? x With the patient, choose an appropriate action for each problem
x How to store records, and for how long? x Involve the patient in planning their management
x With whom to share the record? x Make effective use of the consultation
How to use the information records contain x Establish or maintain a relationship with the patient
x To manage my patients?
x To audit and improve my service?
x To support my research?
x To feed another information system?
How to communicate with my colleagues and patients
x Face to face? Ms Smith is a 58 year old florist with a 15 year history of
x On paper? renal impairment caused by childhood pyelonephritis
x Using the internet? who is experiencing tiredness and muscle cramps. She
Clinical knowledge sources has sought medical attention for similar problems in the
x What knowledge sources are out there, and how to select them? past, and is considering doing so again
x How to use these sources to answer my own, and my team’s, clinical
questions?
x How to keep knowledge and skills up to date?
x How to use knowledge to improve my own, and my team’s, clinical
practice? Clinical encounter
Directory of staff,
services...
Capturing and using information Refers to
Dr Jones Ms Smith
Consider the different forms that information can take, where (consultant) Takes (patient)
each form comes from, its cost, and how to assess the quality of action
Communicates
the information. These issues arise during a general with Captures
Accesses data from
practitioner’s (Dr McKay) encounter with Ms Smith. knowledge in Dr McKay
Dr McKay applies her own clinical knowledge and skill, (general practitioner)
perhaps augmented by a textbook or other knowledge source,
Records data in,
to capture relevant data from Ms Smith. Dr McKay browses Ms uses data from
Smith’s record to check her medical history. She updates the
record and either takes action herself, or telephones a Knowledge resource Patient record
consultant nephrologist (Dr Jones), who suggests 1 -hydroxy
cholecalciferol 0.5 g daily for Ms Smith. Dr McKay then Information flows in a clinical environment
follows up the telephone conversation with the consultant by
issuing an electronic prescription. The prescription transfers
through a secure local network to Ms Smith’s usual pharmacist
566 BMJ VOLUME 331 10 SEPTEMBER 2005 bmj.com
2. Clinical review
along with a formal online outpatient referral request. Dr Jones
Common sense meets semiotic theory
checks a hospital phone directory on the web before referring
Ms Smith to the dietician for a low calcium diet. Ms Smith is In her shop, Ms Smith sells a kind of flower that grows on shrubs with
prickly stems and serrated leaves. Humans use consistent symbols to
kept informed of these developments by telephone before her
represent these things (for example, “rose; roos”). However, each
appointment the next week. person privately adds their own connotations to these symbols
Some definitions of rose from Chambers 21st Century Dictionary
x An erect or climbing thorny shrub that produces large, often
Representing, interpreting and fragrant, flowers that may be red, pink, yellow, orange, or white, or
displaying information combinations of these colours, followed by bright-coloured fleshy
fruits
When Dr McKay reads Ms Smith’s patient record what she sees x The national emblem of England
on the page is not actually information, but a representation of x A light pink, glowing complexion (put the roses back in one’s
it. A “real” item of information, such as the fact that Ms Smith cheeks)
x A perforated nozzle, usually attached to the end of a hose, watering
has hypercalcaemia, is distinct from how that item is
can, or shower head that makes the water come out in a spray
represented in an information system (for example, by selecting
Ms Smith’s record and writing “Hypercalcaemia,” or choosing a
Read code that updates Ms Smith’s computer-based record).
The real information is also distinct from a person’s
interpretation of it, which might resemble a fragment in a
stream of consciousness, “Remember to check on Ms
Smith—calcium problem back again.” These distinctions reflect
common sense and semiotic theory: real things only exist in the
physical world, and each person interprets them in private and
associates their own images with them.
Back in the clinical world, the lesson is that we should
capture and represent each item of information in a form that
helps each user—whether human or computer—to find and
interpret it. The next time Dr McKay logs into Ms Smith’s
computer record, although Ms Smith’s serum calcium may be
represented internally in the computer as the real number 2.8,
on the computer screen it can be shown as a figure, a red
warning icon, a point on a graph showing all her calcium
results, or as the words “Severe hypercalcaemia” in an alert.
These display formats can all be achieved with a paper record,
but it would take more time and effort to annotate abnormal Possible formats to display information include informal or structured text,
tables, graphs, sketches, and images. The best format for each item of
laboratory results with a highlighter pen, graph the values on a information depends on who will use it, how they will use it, for what task,
paper chart, or write an alert on a Post-it note and place this on and on the formats readily available. With permission from Klaus
the front of Ms Smith’s record. Gulbrandsen/SPL
Selecting a format is important because it determines how
to represent each item of information in a system, and in turn
how each item is captured. When information is captured and
represented on paper or film, it is hard to change the order in Clinical environment Directory of staff,
which each item appears or to display it in other formats. When services...
information is captured and stored on a computer, however, it Refers to
can be shown in a different order or grouped in different ways.
Dr Jones Ms Smith
When data is coded and structured, or broken down into simple (consultant) Takes (patient)
elements, it can be processed automatically—for example, the action
Communicates
computer can add the icon, graph the data, or generate the alert with Captures
Accesses data from
about Ms Smith. knowledge in Dr McKay
(general practitioner)
Sources of clinical information Records data in,
uses data from
Clinicians use three types of information to support patient Quality
Knowledge resource Patient record
care: patient data, medical knowledge, and “directory” improvement
information. This description ignores two questions, however: actions
where does the knowledge in a textbook come from, and how Content Data extraction,
assembly checking
do we improve on the methods used to manage patients?
Patient data are the source in both cases (see box opposite).
Generic clinical Registry etc Local problem
Local problems—such as an adverse event or failure to solution (evidence) or opportunity
Clinical Clinical
implement a guideline that everyone agrees to apply to their research audit,
patients—can be picked up by quality improvement activities quality activity
such as clinical governance. In well organised clinical
environments and specialties, a registry is used to capture Information flows in clinical and non-clinical environments
patient experiences and monitor for adverse outcomes.
Sometimes, however, patient data are used to suggest, or
even answer, more general questions—for example, about drug
BMJ VOLUME 331 10 SEPTEMBER 2005 bmj.com 567
3. Clinical review
effectiveness, disease aetiology, or the accuracy of tests. The
results should be high quality, generic evidence that can be Diseases
safely applied outside the specific clinical environment that is
being studied. Often, this evidence is published as if it were the Renal diseases
final word. Clinical epidemiology shows us, however, that the
Chronic diseases
results of a single study often differ substantially from the
“truth.” Well conducted systematic reviews of all rigorous, Chronic pyelonephritis
relevant studies are a better approximation, and are an example
of the content assembly methods used to develop good quality Chronic renal impairment
knowledge resources.
Secondary hyperparathyroidism
The costs of information Partial hierarchy of diseases
To a businessman, information must seem the ultimate product:
once it is captured, it can be sold any number of times without Quality criteria for patient data
using up the original supply. Unfortunately for clinicians, each
item of information that is captured, processed, and displayed Criterion How to test it Comment
has an associated cost or risk. By choosing to code the current Accurate Comparison with a gold Technically, validity—does
problem as chronic pyelonephritis only (see figure above), Dr standard source of the data item measure what
data—for example, the it is meant to? Reliability is
McKay fails to record the endocrine dimension with potential patient a related concept—do two
loss of explanatory power for others looking at Ms Smith’s observers agree on the data
records. Entering more than one code takes extra time and may item?
cause difficulties in interpretation for secondary use of the data. Complete Per cent missing data at Often difficult to estimate
Information costs are especially high for data captured by a given point without access to multiple
health professionals in the structured, coded representation often sources of information
required by computerised record systems. If the information is Timely Delay from the event Unless data are available at
only ever going to be read by humans, it should not be captured the data describes to its the point they are needed
availability for use on to inform decisions,
as structured data because this will discourage doctors from
the information system fulfilling the other criteria
recording useful free text that computers do not need to is almost worthless
“understand”—for example, “Ms Smith is going to Spain for a Relevant Amount that data alter Unless data are relevant to
holiday, her cat died last week.” All patient record systems should decisions or actions of information users, they
allow easy entry of such unstructured text (perhaps by voice the user; the impact of contribute to information
recognition) to support the human side of medicine, and to help leaving an item out of overload
maintain the therapeutic relationship with patients. the dataset
Appropriately Degree of structuring Depends on the user of
represented and coding of items the item and their needs
Assessing the quality of information Relevant detail If data are detailed Highly dependent on the
included enough to support purpose and
Imagine that Dr Jones is auditing outcomes in his decisions confidentiality of the
hypercalcaemic patients and wishes to include Ms Smith’s data. information
Is her data of adequate quality for this task? Relevant Is there enough context A key issue, only partially
Information only exists to support decisions and actions: if context (for example, date solved in current
it fails to do this, it is irrelevant noise. The aims of clinical audit included patient seen, by whom) electronic patient records
are to understand current practice and suggest appropriate to support appropriate
actions for the future. If the data are full of errors or interpretation of data?
incomplete, refer to patients seen years ago, or cannot be
interpreted by the user, they are unlikely to help. More subtly, if
Further reading
useful data items are present—for example, serum calcium—but
vital context is omitted, such as serum albumin or current x Hersh W. What is Medical Informatics? www.ohsu.edu/dmice/
whatis/index.shtml (accessed 26 August 2005)
treatment, it is still hard to use the data. Without this context,
x Pendleton D, Schofield T, Tate P, Havelock P. The consultation: an
information is often useless; with it, data collected for one approach to learning and teaching. Oxford: Oxford University Press,
purpose can often, but not always, be used for another. 1987
x Nygren E, Wyatt JC, Wright P. Medical records 2: helping clinicians
find information and avoid delays. Lancet 1998;352:1462-6
Glossaries for informatics terms x Morris AD, Boyle DI, MacAlpine R, Emslie-Smith A, Jung RT,
x Coiera E. Guide to health informatics. 2nd ed. London: Hodder Newton RW, et al. The diabetes audit and research in Tayside
Arnold, 2003. www.coiera.com/glossary.htm (accessed 26 August Scotland (DARTS) study: electronic record linkage to create a
2005) diabetes register. DARTS/MEMO Collaboration. BMJ
x Wyatt JC, Liu J. Basic concepts in medical informatics. 1997;315:524-8
http://jech.bmjjournals.com/cgi/content/full/56/11/808 x Naylor CD. Grey zones of clinical practice: some limits to evidence
(accessed 26 August 2005) based medicine. Lancet 1995;345:840-2
x Brody H. Stories of sickness. Yale: Yale University Press, 1987
Jeremy C Wyatt is professor of health informatics, and Frank Sullivan x Tanenbaum SJ. What physicians know. N Engl J Med
is NHS Tayside professor of research and development in general 1996.329:1268-71
practice and primary care, University of Dundee. x van Bemmel JH, Musen MA, eds. Handbook of medical informatics.
London: Springer, 1997 www.mihandbook.stanford.edu/
The series will be published as a book by Blackwell Publishing in
spring 2006. handbook/home.htm (accessed 26 August 2005)
Competing interests: none declared BMJ 2005;331:566–8
568 BMJ VOLUME 331 10 SEPTEMBER 2005 bmj.com