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Hospital Information Systems (HIS) handle a large number of different types of documents. Exchange and analysis of data from different HIS is facilitated by the use of standardized codes to identify document types. HL7's Clinical Document Architecture (CDA) uses LOINC (logical observation identifiers names and Codes) codes for clinical documents. The authors assessed the coverage of LOINC codes for document types in a German HIS. The authors analyzed document types [...]

We explored automated concept-based indexing of unstructured figure captions to improve retrieval of images from radiology journals.

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

Many biomedical terminologies, classifications, and ontological resources such as the NCI Thesaurus (NCIT), International Classification of Diseases (ICD), Systematized Nomenclature of Medicine (SNOMED), Current Procedural Terminology (CPT), and Gene Ontology (GO) have been developed and used to build a variety of IT applications in biology, biomedicine, and health care settings. However, virtually all these resources involve incompatible formats, are based on different modeling languages, and lack appropriate tooling and programming [...]

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

The authors implemented what is possibly the first secure messaging system in a VA Medical Center. Since reimbursement for secure messaging is not of great concern and clinical data systems are fully computerized, several evaluation strategies were used to assess clinical adoption. To address known concerns of clinicians, the authors analyzed secure messaging use and performed a content analysis. Message volumes were low and content analysis demonstrated that messages were [...]

The purpose of this study was to evaluate the adequacy of the International Classification of Nursing Practice (1) (ICPN) Version 1.0 as a representational model for nursing assessment documentation.

The Program Requirements for Fellowship Education identify the knowledge and skills that physicians must master through the course of a training program to be certified in the subspecialty of clinical informatics. They also specify accreditation requirements for clinical informatics training programs. The AMIA Board of Directors approved this document in November 2008.

The active engagement of consumers is an important factor in achieving widespread success of health information systems. The disability community represents a major segment of the healthcare arena, with more than 50 million Americans experiencing some form of disability. In keeping with the "consumer-driven" approach to e-health systems, this paper considers the distinctive aspects of electronic and personal health record use by this segment of society. Drawing upon the information [...]