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Retention policies for clinical records are set primarily by the states, although the federal government mandates minimum maintenance periods for certain classes of patients and selected types of information. State policies vary considerably, but most jurisdictions permit many types of data to be destroyed after some period usually shorter than 10 years. Many health care organizations hold records longer than mandated, but over time much clinical data are discarded or [...]

The authors study two approaches to assertion classification. One of these approaches, Extended NegEx (ENegEx), extends the rule-based NegEx algorithm to cover alter-association assertions; the other, Statistical Assertion Classifier (StAC), presents a machine learning solution to assertion classification.

Spatio and/or temporal surveillance systems are designed to monitor the ongoing appearance of disease cases in space and time, and to detect potential disturbances in either dimension. Patient addresses are sometimes reported at some level of geographic aggregation, for example by ZIP code or census tract. While this aggregation has the advantage of protecting patient privacy, it also risks compromising statistical efficiency. This paper investigated the variation in power to [...]

The National Resource Center for Health Information Technology (NRC) was formed in the fall of 2004 as part of the Agency for Healthcare Research and Quality (AHRQ) health IT portfolio to support its grantees. One of the core functions of the NRC was to assist grantees in their evaluation efforts of Health IT. This manuscript highlights some common challenges experienced by health IT project teams at nonacademic institutions, including inappropriately [...]

Technology has great potential to reduce medication errors in hospitals. This case report describes barriers to, and facilitators of, the implementation of a pharmacy bar code scanning system to reduce medication dispensing errors at a large academic medical center. Ten pharmacy staff were interviewed about their experiences during the implementation. Interview notes were iteratively reviewed to identify common themes. The authors identified three main barriers to pharmacy bar code scanning [...]

The Internet's potential to bolster health promotion and disease prevention efforts has attracted considerable attention. Existing research leaves two things unclear, however: the prevalence of online health and medical information seeking and the distinguishing characteristics of individuals who seek that information.

OBJECTIVE To facilitate patient handoffs between physicians, the computerized patient handoff tool (PHT) extracts information from the electronic health record to populate a form that is printed and given to the cross-cover physician. OBJECTIVES were to: (1) evaluate the rate at which data elements of interest were extracted from the electronic health record into the PHT, (2) assess the frequency for needing information beyond that contained in the PHT and [...]

OBJECTIVE To compare the experiences of e-prescribing users and nonusers regarding prescription safety and workload and to assess the use of information from two e-prescribing standards (for medication history and formulary and benefit information), as they are implemented. DESIGN Cross-sectional survey of physicians who either had installed or were awaiting installation of one of two commercial e-prescribing systems. MEASUREMENTS Perceptions about medication history and formulary and benefit information among all [...]

OBJECTIVE Evaluate the effectiveness of a simple rule-based approach in classifying medical discharge summaries according to indicators for obesity and 15 associated co-morbidities as part of the 2008 i2b2 Obesity Challenge. METHODS The authors applied a rule-based approach that looked for occurrences of morbidity-related keywords and identified the types of assertions in which those keywords occurred. The documents were then classified using a simple scoring algorithm based on a mapping [...]