Budd-Chiari syndrome (BCS): a challenging diagnosis not to be overlooked-single center report and pictorial essay.

Budd-Chiari syndrome (BCS) is a rare disease with a variable clinical presentation and often late diagnosis. Doppler ultrasonography (DUS) permits to determine the site of the obstructed venous tracts, the thrombotic or non-thrombotic nature of the obstruction with its morphologic features and the flow-pattern alterations. Other non-specific findings, which are seen in most of the other liver diseases, include ascites, hepatosplenomegaly and caudate hypertrophy. The aim of this study is to show our experience in BCS reporting retrospectively 15 cases referred to our hepatology center between 2017 and 2021. Four selected cases depict the extreme heterogeneous behaviour of BCS and highlight the importance of DUS as a diagnostic tool when there is a clinical suspicion. In patients, mainly young, who present with ascites and abdominal pain, BCS has to be considered and DUS is the first imaging technique to be performed to rule it out.

Correlates of online health information-seeking behaviors in a low-income Hispanic community.

OBJECTIVE: The purpose of this study was to explore the correlates of online health information-seeking behaviors among Hispanic residents of a low-income urban neighborhood. METHODS: Data were collected with a community survey from 1045 unique participants at ambulatory care clinics in a largely Hispanic immigrant community in northern Manhattan, New York. A descriptive correlational analysis was conducted using logistic regression. RESULTS: A majority of the participants were born outside the United States (85.7%), and half (50.3%) had completed high school. A logistic regression revealed that five independent variables were significantly correlated with online health information-seeking behaviors: age, education, marital status, primary language, and health literacy. Age and Spanish as preferred language were negatively associated with online health information-seeking (OR = 0.93 and 0.50), whereas education and health literacy were positively associated with online health information-seeking (OR = 4.28 and 1.28). CONCLUSIONS: The findings have implications for designing online health information resources and interventions appropriate for the populations they are likely to reach. Furthermore, the findings highlight the need for special efforts to ensure access to reliable health information for immigrant populations and those with low health literacy.

An informatics infrastructure is essential for evidence-based practice.

The contention of the author is that an informatics infrastructure is essential for evidenced-based practice. Five building blocks of an informatics infrastructure for evidence-based practice are proposed: 1) standardized terminologies and structures, 2) digital sources of evidence, 3) standards that facilitate health care data exchange among heterogeneous systems, 4) informatics processes that support the acquisition and application of evidence to a specific clinical situation, and 5) informatics competencies. Selected examples illustrate how each of these building blocks supports the application of evidence to practice and the building of evidence from practice. Although a number of major challenges remain, medical informatics can provide solutions that have the potential to decrease unintended variation in practice and health care errors.

Collaborative efforts for representing nursing concepts in computer-based systems: international perspectives.

Current nursing terminology efforts have converged toward meeting the demand for a reference terminology for nursing concepts by building on the foundation of existing interface and administrative terminologies and by collaborating with terminology efforts across the spectrum of health care. In this article, the authors illustrate how collaboration is promoting convergence toward a reference terminology for nursing by briefly summarizing a wide range of exemplary activities. These include: 1) the International Classification of Nursing Practice (ICNP) activities of the International Council of Nurses (ICN), 2) work in Brazil and Korea that has contributed to, and been stimulated by, ICNP developments, 3) efforts in the United States to improve understanding of the different types of terminologies needed in nursing and to promote harmonization and linking among them, and 4) current nursing participation in major multi-disciplinary standards initiatives. Although early nursing terminology work occurred primarily in isolation and resulted in some duplicative efforts, the activities summarized in this article demonstrate a tremendous level of collaboration and convergence not only in the discipline of nursing but in multi-disciplinary standards initiatives. These efforts are an important prerequisite for ensuring that nursing concepts are represented in computer-based systems in a manner that facilitates multi-purpose use at local, national, regional, and international levels.

Representing nursing activities within a concept-oriented terminological system: evaluation of a type definition.

OBJECTIVE: A type definition, as a component of the categorical structures of a concept-oriented terminology, must support nonambiguous concept representations and, consequently, comparisons of data that are represented using different terminologies. The purpose of the study was to evaluate the adequacy and utility of a proposed type definition for nursing activity concepts. DESIGN: Nursing activity terms (n = 1039) from patient charts and intervention terms from two nursing terminologies (Home Health Care Classification and Omaha System) were decomposed into the attributes of the proposed type definition-Delivery Mode, Activity Focus, and Recipient. MEASUREMENTS: Attributes of the type definition were coded as present or absent for each term by multiple raters. In addition, Delivery Mode was rated as Explicit or Implicit and Recipient was rated as Explicit, Implicit, or Ambiguous. The data were summarized using descriptive statistics. Inter-rater reliabilities were calculated for each attribute of the type definition. RESULTS: All attributes of the type definition were present in 73.9 percent of the chart terms, 91.3 percent of Home Health Care Classification intervention terms, and 63.5 percent of Omaha System intervention terms. While Delivery Mode and Activity Focus were almost universally present, Recipient was problematic. It was rated as ambiguous in 4.8 percent of the chart terms, 8.7 percent of Home Health Care Classification intervention terms, and 36.5 percent of Omaha System intervention terms. CONCLUSIONS: The study findings supported the adequacy and utility of the type definition. Further research is needed to refine the type definition and its use for representing nursing activity concepts within a concept-oriented terminological system.

Toward vocabulary domain specifications for health level 7-coded data elements.

The "vocabulary problem" has long plagued the developers, implementers, and users of computer-based systems. The authors review selected activities of the Health Level 7 (HL7) Vocabulary Technical Committee that are related to vocabulary domain specification for HL7 coded data elements. These activities include: 1) the development of two sets of principles to provide guidance to terminology stakeholders, including organizations seeking to deploy HL7-compliant systems, terminology developers, and terminology integrators; 2) the completion of a survey of terminology developers; 3) the development of a process for HL7 registration of terminologies; and 4) the maintenance of vocabulary domain specification tables. As background, vocabulary domain specification is defined and the relationship between the HL7 Reference Information Model and vocabulary domain specification is described. The activities of the Vocabulary Technical Committee complement the efforts of terminology developers and other stakeholders. These activities are aimed at realizing semantic interoperability in the context of the HL7 Message Development Framework, so that information exchange and use among disparate systems can occur for the delivery and management of direct clinical care as well as for purposes such as clinical research, outcome research, and population health management.

Evaluation of the clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures.

OBJECTIVE: The purpose of this study was to test the adequacy of the Clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures. METHODS: After extension of the definitions, 1, 096 items from 35 standardized assessment instruments were dissected into the elements of the Clinical LOINC semantic structure. An additional coder dissected at least one randomly selected item from each instrument. When multiple scale types occurred in a single instrument, a second coder dissected one randomly selected item representative of each scale type. RESULTS: The results support the adequacy of the Clinical LOINC semantic structure as a terminology model for standardized assessments. Using the revised definitions, the coders were able to dissect into the elements of Clinical LOINC all the standardized assessment items in the sample instruments. Percentage agreement for each element was as follows: component, 100 percent; property, 87.8 percent; timing, 82.9 percent; system/sample, 100 percent; scale, 92.6 percent; and method, 97.6 percent. DISCUSSION: This evaluation was an initial step toward the representation of standardized assessment items in a manner that facilitates data sharing and re-use. Further clarification of the definitions, especially those related to time and property, is required to improve inter-rater reliability and to harmonize the representations with similar items already in LOINC.

Relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS.

The purpose of this descriptive, correlational study was to examine the relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS. The convenience sample of 707 non-hospitalized persons receiving health care for HIV/AIDS was recruited from seven U.S. sites. All measures were self-report. Perception of engagement with health care provider was measured by the newly developed Engagement with Health Care Provider scale. Adherence to therapeutic regimen included adherence to medications, provider advice, and appointments. Health status was measured by the Medical Outcomes Study Short Form 36 (MOS SF-36), Living with HIV scale, CD4 count, and length of time known to be HIV-positive. There were no significant relationships between engagement with health care provider and age, gender, ethnicity, and type of health care provider. Subscales of the MOS SF-36 and Living with HIV explained a significant, but modest amount of the variance in engagement. Clients who were more engaged with their health care provider reported greater adherence to medication regimen and provider advice. Clients who missed at least one appointment in the last month or who reported current or past injection drug use were significantly less engaged.

The revised Sign and Symptom Check-List for HIV (SSC-HIVrev).

Symptom management for persons living with HIV/AIDS is recognized as an extremely important component of care management. This article reports on the continuing validation of the revised Sign and Symptom Check-List for Persons With HIV Disease (SSC-HIVrev). The initial validation study used a combined sample of 933 HIV-positive persons and concluded that the validity and reliability of the instrument were adequate to measure patients' self-report of HIV-related signs and symptoms. The revised scale includes items to measure gynecological-related symptoms and the impact of lipodystrophy (body fat redistribution) due to antiretroviral therapy on patients' symptom experience. The scale structure (factor analysis) and reliability estimates were recalculated in a new sample of 372 HIV-positive persons. Based on reviewing the clusters of items, factor loadings, reliability estimates, and clinical interpretability, an 11-factor solution was determined that explained 73.3% of the variance. Of the retained factors, 4 had eigenvalues less than 1, yet they explained significant amounts of variance in the rotated sums of squares loading (5.0%, 4.3%, 4.3%, and 3.6%, respectively), the reliability estimates were good, and the factors had clinical meaning. The revised scale (SSC-HIVrev) has three parts: Part 1 consists of 45 items that clustered into 11 factor scores along with a total score, with reliability estimates ranging from .76 to .91; Part 2 consists of 19 HIV-related symptoms that do not cluster into factor scores but may be of interest from a clinical perspective; and Part 3 consists of 8 items related to gynecological symptoms for women. These 8 items were submitted to a principal components factor analysis with varimax rotation (n = 118 HIV-positive women), and a 1-factor solution explained 71.8% of the variance, with a reliability estimate of .94. The psychometric properties of the SSC-HIVrev are presented.

Predictors of perception of cognitive functioning in HIV/AIDS.

This is a descriptive, correlational study of the predictors of perceived cognitive functioning. The convenience sample of 728 nonhospitalized persons receiving health care for HIV/AIDS was recruited from seven sites in the United States. All measures were self-reported. Self-perception of cognitive functioning, the dependent variable, was composed of three items from the Medical Outcomes Study HIV scale: thinking, attention, and forgetfulness. Data related to age, gender, ethnicity, education, injection drug use, CD4 count, and length of time known to be HIV-positive were collected on a demographic questionnaire. The scale from the Sign and Symptom Checklist for Persons with HIV Disease was used to measure self-reported symptoms. Data were analyzed using hierarchical multiple regression analysis. Predictors of perception of cognitive functioning explained a total of 36.3% of the variance. Four blocks--person variables (1.5%) (age, gender, education, history of injection drug use), disease status (2.3%), symptom status (26.5%), and functional status (5.4%)--significantly contributed statistically to the total variance. Among those individuals who completed the questions related to depression (n = 450), 28% of the variance in cognitive functioning was explained by this variable. The findings in this multi-site study indicate that symptom status explained the largest amount of variance in perceived cognitive functioning. Early identification of cognitive impairment can result in appropriate clinical interventions in remediable conditions and in the improvement of quality of life.

An evaluation of the usefulness of two terminology models for integrating nursing diagnosis concepts into SNOMED Clinical Terms.

OBJECTIVES: We evaluated the usefulness of two models for integrating nursing diagnosis concepts into SNOMED Clinical Terms (CT). METHODS: First, we dissected nursing diagnosis term phrases from two source terminologies (North American Nursing Diagnosis Association Taxonomy 1 (NANDA) and Omaha System) into the semantic categories of the European Committee for Standardization (CEN) categorical structure and ISO reference terminology model (RTM). Second, we critically analyzed the similarities between the semantic links in the CEN and ISO models and the semantic links used to formally define diagnostic concepts in SNOMED CT. RESULTS: Our findings demonstrated that focus, bearer/subject of information, and judgment were present in 100% of the NANDA and Omaha term phrases. The Omaha term phrases contained no additional descriptors beyond those considered mandatory in the CEN and ISO models. The comparison among the semantic links showed that SNOMED CT currently contains all but one of the semantic links needed to model the two source terminologies for integration. In conclusion, our findings support the potential utility of the CEN and ISO models for integrating nursing diagnostic concepts into SNOMED CT.

Standardized nursing vocabularies: a foundation for quality care.

OBJECTIVES: To describe the importance of standardized nursing vocabularies as a foundation for quality in health care decision-making. DATA SOURCES: Literature, online sources, and committee documents. CONCLUSIONS: Several standardized vocabularies are recognized by the American Nurses Association Committee for Nursing Practice Information Infrastructure. Vendors also have integrated the vocabularies into their information systems. Future efforts include developing an international nursing reference terminology. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses face quality of care issues that impact decision-making at the point of care. To describe their practice, oncology nurses must strive to use nursing data that are standardized, documented, and made visible by inclusion in computer-based systems.

An evaluation of the utility of the CEN categorical structure for nursing diagnoses as a terminology model for integrating nursing diagnosis concepts into SNOMED.

We evaluated the utility of the CEN Categorical Structure for Nursing Diagnoses as a terminology model for integrating nursing diagnosis concepts into SNOMED. First, we dissected nursing diagnosis term phrases from two source terminologies (North American Nursing Diagnosis Association (NANDA) Taxonomy 1 and Omaha System) into the semantic categories of the CEN categorical structure. Second, we critically analyzed the similarities between the semantic links in the CEN model and the semantic links used to formally define diagnostic concepts in SNOMED RT and SNOMED CT. Our findings demonstrated that focus, bearer, and judgment were present in 100% of the NANDA and Omaha term phrases. The Omaha term phrases contained no additional descriptors beyond those considered mandatory in the CEN model. In contrast, at least 3% of NANDA diagnoses included a term in each semantic category of the categorical structure. The comparison among the semantic links showed that neither SNOMED RT and SNOMED CT currently contain all the semantic links needed to model the two source terminologies for integration. In conclusion, our findings support the potential utility of the CEN categorical structure as a terminology model for dissecting nursing diagnostic concepts for integration into SNOMED RT and SNOMED CT. However, in order to accomplish this task, appropriate semantic links must be added to SNOMED RT and SNOMED CT.

The nursing terminology summit: collaboration for progress.

The Nursing Terminology Summit has used collaborative processes to bring about significant changes in the development of terminology standards for nursing. This paper draws on agendas, reports, notes, and other documents from the Summit, in addition to the authors' own experience as Organizer, Steering Committee, and participants, to provide a brief history of the Summit process. The analysis identifies factors that increased the risk of failure as well as factors that fostered success. The paper concludes with lessons learned that can be applied in other arenas to promote change in medical informatics.

Cognitive analysis of decision support for antibiotic ordering in a neonatal intensive care unit.

BACKGROUND: Clinical decision support systems (CDSS) are a method used to support prescribing accuracy when deployed within a computerized provider order entry system (CPOE). Divergence from using CDSS is exemplified by high alert override rates. Excessive cognitive load imposed by the CDSS may help to explain such high rates. OBJECTIVES: The aim of this study was to describe the cognitive impact of a CPOE-integrated CDSS by categorizing system use problems according to the type of mental processing required to resolve them. METHODS: A qualitative, descriptive design was used employing two methods; a cognitive walkthrough and a think-aloud protocol. Data analysis was guided by Norman's Theory of Action and a theory of cognitive distances which is an extension to Norman's theory. RESULTS: The most frequently occurring source of excess cognitive effort was poor information timing. Information presented by the CDSS was often presented after clinicians required the information for decision making. Additional sources of effort included use of language that was not clear to the user, vague icons, and lack of cues to guide users through tasks. CONCLUSIONS: Lack of coordination between clinician's task-related thought processes and those presented by a CDSS results in excessive cognitive work required to use the system. This can lead to alert overrides and user errors. Close attention to user's cognitive processes as they carry out clinical tasks prior to CDSS development may provide key information for system design that supports clinical tasks and reduces cognitive effort.

Visual clustering analysis of CIS logs to inform creation of a user-configurable Web CIS interface.

BACKGROUND: In this paper, we describe a new method for the study of clinical information system (CIS) logfiles joined with information in the clinical data warehouse. This method uses heatmap representations and clustering techniques to examine clinicians' viewing patterns of laboratory test results. The context of our application of these techniques is to inform the creation of a widget-based interface to the CIS. OBJECTIVES: We address the rationale, feasibility, and usefulness of our method through examination of three hypotheses: 1) The frequency distribution of laboratory test viewing will follow a 'long tail' pattern, indicating that patterns are highly variable and supporting the rationale for a widget-based configurable system. 2) Patterns of laboratory testing viewing (by clinician, specialty, clinician/patient/day, and ICD-9-CM codes) can be distinguished by our methods. 3) The identified clusters will include more than 80% of the laboratory test elements found in 30 randomly selected patient records for one day. METHODS: The data were plotted as heatmaps and clustered using hierarchical clustering software. Various parameters were tested to give the optimal clusters. RESULTS: All the hypotheses were supported. For Hypothesis 3, 91.4% of information elements in the records were covered by the generated clusters. CONCLUSIONS: Study findings support the rationale, feasibility, and usefulness of our methods to examine patterns of information access among clinicians and to inform the creation of widget-based interfaces. The results also contribute to our general understanding of clinicians' CIS use.

Clinician preferences for verbal communication compared to EHR documentation in the ICU.

BACKGROUND: Effective communication is essential to safe and efficient patient care. Additionally, many health information technology (HIT) developments, innovations, and standards aim to implement processes to improve data quality and integrity of electronic health records (EHR) for the purpose of clinical information exchange and communication. OBJECTIVE: We aimed to understand the current patterns and perceptions of communication of common goals in the ICU using the distributed cognition and clinical communication space theoretical frameworks. METHODS: We conducted a focus group and 5 interviews with ICU clinicians and observed 59.5 hours of interdisciplinary ICU morning rounds. RESULTS: Clinicians used an EHR system, which included electronic documentation and computerized provider order entry (CPOE), and paper artifacts for documentation; yet, preferred the verbal communication space as a method of information exchange because they perceived that the documentation was often not updated or efficient for information retrieval. These perceptions that the EHR is a "shift behind" may lead to a further reliance on verbal information exchange, which is a valuable clinical communication activity, yet, is subject to information loss. CONCLUSIONS: Electronic documentation tools that, in real time, capture information that is currently verbally communicated may increase the effectiveness of communication.

Representing patient preference-related concepts for inclusion in electronic health records.

In recent years shared decision making between patients and their health care providers and the inclusion of patient preferences in patient care have been, in theory, embraced as models for good clinical practice. Patients' experiences, values, and preferences are increasingly acknowledged as important pieces of evidence for appropriate health care decision making. To effectively use information about patient preferences in patient care, this information, which is gathered through a process of preference elicitation, needs to be integrated with other types of information, e.g., diagnoses, treatments, and patient status indicators within the context of a longitudinal electronic health record. This integration requires that patient preference-related concepts be represented nonambiguously and in a manner that renders them suitable for computer rather than human processing. In this article, the authors describe important patient preference-related concepts and illustrate the use of the LOINC semantic structure as a terminology model to create fully specified names for a sample of 15 preference elicitations from 8 published research articles.