Literature DB >> 23304349

Who said it? Establishing professional attribution among authors of Veterans' Electronic Health Records.

Ruth M Reeves1, Fern FitzHenry, Steve H Brown, Kristen Kotter, Glenn T Gobbel, Diane Montella, Harvey J Murff, Ted Speroff, Michael E Matheny.   

Abstract

BACKGROUND: A practical data point for assessing information quality and value in the Electronic Health Record (EHR) is the professional category of the EHR author. We evaluated and compared free form electronic signatures against LOINC note titles in categorizing the profession of EHR authors.
METHODS: A random 1000 clinical document sample was selected and divided into 500 document sets for training and testing. The gold standard for provider classification was generated by dual clinician manual review, disagreements resolved by a third reviewer. Text matching algorithms composed of document titles and author electronic signatures for provider classification were developed on the training set.
RESULTS: Overall, detection of professional classification by note titles alone resulted in 76.1% sensitivity and 69.4% specificity. The aggregate of note titles with electronic signatures resulted in 95.7% sensitivity and 98.5% specificity.
CONCLUSIONS: Note titles alone provided fair professional classification. Inclusion of author electronic signatures significantly boosted classification performance.

Keywords:  EHR meta-data; Health-care profession; LOINC title; document quality; electronic signature

Mesh:

Year:  2012        PMID: 23304349      PMCID: PMC3540586     

Source DB:  PubMed          Journal:  AMIA Annu Symp Proc        ISSN: 1559-4076


  9 in total

1.  Derivation and evaluation of a document-naming nomenclature.

Authors:  S H Brown; M Lincoln; S Hardenbrook; O N Petukhova; S T Rosenbloom; P Carpenter; P Elkin
Journal:  J Am Med Inform Assoc       Date:  2001 Jul-Aug       Impact factor: 4.497

2.  The creation of an ontology of clinical document names.

Authors:  P Frazier; A Rossi-Mori; R H Dolin; L Alschuler; S M Huff
Journal:  Stud Health Technol Inform       Date:  2001

3.  VistA--U.S. Department of Veterans Affairs national-scale HIS.

Authors:  Steven H Brown; Michael J Lincoln; Peter J Groen; Robert M Kolodner
Journal:  Int J Med Inform       Date:  2003-03       Impact factor: 4.046

4.  Medical errors as a result of specialization.

Authors:  Ahmad Hashem; Michelene T H Chi; Charles P Friedman
Journal:  J Biomed Inform       Date:  2003 Feb-Apr       Impact factor: 6.317

5.  Coding consultation E/M services correctly.

Authors:  Karla R Peter
Journal:  J AHIMA       Date:  2006 Nov-Dec

6.  Iterative evaluation of the Health Level 7--Logical Observation Identifiers Names and Codes Clinical Document Ontology for representing clinical document names: a case report.

Authors:  Sookyung Hyun; Jason S Shapiro; Genevieve Melton; Cara Schlegel; Peter D Stetson; Stephen B Johnson; Suzanne Bakken
Journal:  J Am Med Inform Assoc       Date:  2009-03-04       Impact factor: 4.497

7.  Electronic signature, attestation, and authorship (updated).

Authors:  Donna Barron; Lauren Blumenthal; Suzonne Bourque; Natasha Brovarny; Jennifer Childress; Jill S Clark; Dawn L Criswell; Julie Dillard; Michelle Dougherty; Marie Gardenier; Darice Gryzbowski; Terri Hall; Marla Hardison; Janice Hecht; Beth Hjort; Kim Jackson; Mary Johnson; Diane M Lerch; Dorothy W Maxim; David Ike Mozie; Indra Osi; Deanna Panzarella; Janis L Pavlick; Ulkar Qazen; Sharron Ray; Linda Spurrell; Delores Stephens; Susan Sugg; Kim Vernon; Traci E Waugh; Lou Ann Wiedemann
Journal:  J AHIMA       Date:  2009 Nov-Dec

8.  Standardizing Clinical Document Names Using the HL7/LOINC Document Ontology and LOINC Codes.

Authors:  Elizabeth S Chen; Genevieve B Melton; Mark E Engelstad; Indra Neil Sarkar
Journal:  AMIA Annu Symp Proc       Date:  2010-11-13

9.  Medical student documentation in the medical record: is it a liability?

Authors:  Peter Gliatto; Philip Masters; Reena Karani
Journal:  Mt Sinai J Med       Date:  2009-08
  9 in total

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