Comparison of the accuracy of inpatient morbidity coding with ICD-11 and ICD-10.

BACKGROUND: One of the challenges when transitioning from International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) to International Classification of Diseases, 11th Revision (ICD-11) is to ensure clinical coding accuracy. OBJECTIVE: To determine the accuracy of clinical coding with ICD-11 in comparison with ICD-10 and identify causes of coding errors in real clinical coding environments. METHOD: The study was conducted prospectively in two general hospitals. Medical records of discharged inpatients were coded by hospital clinical coders with both ICD-11 and ICD-10 on different days. These medical records were recoded by five mentors. Codes assigned by mentors were used as the gold standard for the evaluation of accuracy. RESULTS: The accuracy of ICD-10 and ICD-11 coding for 1578 and 2168 codes was evaluated. Coding accuracy was 89.1% and 74.2% for ICD-10 and ICD-11. In ICD-11, the lowest accuracy was observed in chapters 22 (injuries), 10 (ear) and 11 (circulatory) (51.1%, 53.8% and 62.7%, respectively). In both ICD-10 and ICD-11, the most important cause of the coding errors was clinical coders' mistakes (79.5% and 81.8% for ICD-10 and ICD-11, respectively). CONCLUSION: Accuracy of clinical coding with ICD-11 was lower relative to ICD-10. Hence, it is essential to carry out initial preparations, particularly the training of clinical coders based on their needs, as well as the necessary interventions to enhance the documentation of medical records according to ICD-11 before or simultaneous with the country-wide implementation. IMPLICATIONS: Clinical coders need complete training, especially in using extension codes and post-coordination coding. Local ICD-11 guidelines based on the needs of local users and reporting policies should be developed. Furthermore, documentation guidelines based on ICD-11 requirements should be developed.

Usability Assessment of an Electronic Medical Record-Embedded Clinical Decision Support System for Arterial Blood Gas Interpretation.

Since usability is considered a significant success factor for Clinical decision support systems (CDSSs), this study seeks to assess the usability of an electronic medical records-embedded CDSS for arterial blood gas (ABG) interpretation and ordering. The current study was conducted in the general ICU of a teaching hospital, using the System Usability Scale (SUS) and interviews with all anesthesiology residents and intensive care fellows in two rounds of CDSS usability testing. The feedback from the participants was discussed with the research team across a series of meetings, and the second version of CDSS was designed and tailored to participants' feedbacks. Subsequently, the CDSS usability score increased from 67.22±4.58 to 80.00±4.84 (P-value<0.001) through participatory, iterative design and the users' usability testing feedbacks.

First record of Anteon xericum Olmi & van Harten (Hymenoptera, Dryinidae) from Palaearctic region.

The Malaise trap program was implemented to carry out periodic sampling in southeastern Iran, specifically targeting Kerman province, in order to investigate and study specimens belonging to the family Dryinidae. Among the assemblage of collected specimens, notable identifications were made within the subfamily Anteoninae, including the discernment of Anteon xericum Olmi & van Harten. This significant finding signifies a previously unreported occurrence in the Palaearctic region (Iran). A detailed diagnosis of the species, an identification key to Iranian Anteon species, a modified key to the Anteon females of the Eastern Palaearctic, along with a distribution map are provided.

Evaluating the Quality of a Clinical Mobile App for Physicians' CT Scan Ordering Using the MARS Rating Scale.

Given the lack of literature on the contributing factors to adopt mobile applications (apps) among physicians and the crucial role of the quality of the apps in their widespread use, the aim of this study is using the Mobile App Rating Scale (MARS) to evaluate the quality of the head CT scan appropriateness criteria app(HAC app). It was developed to assist medical interns and residents in ordering head CT scans. MARS is internationally recognized as an app rating tool and consists of four objective and subjective quality subscales quality subscale. Although the overall quality score of the HAC app was favorable (82 out of 100), it had low quality scores in the "information" (73.37 out of 100) and the "engagement" (73.48 out of 100) subscales. The HAC app appears to be functional to the physicians; however, it needs to improve its quality in terms of interactivity and effectiveness.

Development and Testing Requirements for an Integrated Maternal and Child Health Information System in Iran: A Design Thinking Case Study.

BACKGROUND: Management of child health care can be negatively affected by incomplete recording, low data quality, and lack of data integration of health management information systems to support decision making and public health program needs. Given the importance of identifying key determinants of child health via capturing and integrating accurate and high-quality information, we aim to address this gap through the development and testing requirements for an integrated child health information system. SUBJECTS AND METHODS: A five-phase design thinking approach including empathizing, defining, ideation, prototyping, and testing was applied. We employed observations and interviews with the health workers at the primary health care network to identify end-users' challenges and needs using tools in human-centered design and focus group discussion. Then, a potential solution to the identified problems was developed as an integrated maternal and child health information system (IMCHIS) prototype and tested using Software Quality Requirements and Evaluation Model (SQuaRE) ISO/IEC 25000. RESULTS: IMCHIS was developed as a web-based system with 74 data elements and seven maternal and child health care requirements. The requirements of "child disease" with weight (0.26), "child nutrition" with weight (0.20), and "prenatal care" with weight (0.16) acquired the maximum weight coefficient. In the testing phase, the highest score with the weight coefficient of 0.48 and 0.73 was attributed to efficiency and functionality characteristics, focusing on software capability to fulfill the tasks that meet users' needs. CONCLUSION: Implementing a successful child health care system integrates both maternal and child health care information systems to track the effect of maternal conditions on child health and support managing performance and optimizing service delivery. The highest quality score of IMCHIS in efficiency and functionality characteristics confirms that it owns the capability to identify key determinants of child health.

Development of clinical-guideline-based mobile application and its effect on head CT scan utilization in neurology and neurosurgery departments.

BACKGROUND: There is little evidence regarding the adoption and intention of using mobile apps by health care professionals (HCP) and the effectiveness of using mobile apps among physicians is still unclear. To address this challenge, the current study seeks two objectives: developing and implementing a head CT scan appropriateness criteria mobile app (HAC app), and investigating the effect of HAC app on CT scan order. METHODS: A one arm intervention quasi experimental study with before/after analysis was conducted in neurology & neurosurgery (N&N) departments at the academic hospital. We recruited all residents' encounters to N&N departments with head CT scan to examine the effect of HAC app on residents' CT scan utilization. The main outcome measure was CT scan order per patient for seven months at three points, before the intervention, during the intervention, after cessation of the intervention -post-intervention follow-up. Data for CT scan utilization were collected by reviewing medical records and then analyzed using descriptive statistics, Kruskal-Wallis, and Mann-Whitney tests. A focus group discussion with residents was performed to review and digest residents' experiences during interaction with the HAC app. RESULTS: Sixteen residents participated in this study; a total of 415 N&N encounters with CT scan order, pre-intervention 127 (30.6%), intervention phase 187 (45.1%), and 101 (24.3%) in the post-intervention follow-up phase were included in this study. Although total CT scan utilization was statistically significant during three-time points of the study (P = 0.027), no significant differences were found for CT utilization after cessation of the intervention (P = 1). CONCLUSION: The effect of mobile devices on residents' CT scan ordering behavior remains open to debate since the changes were not long-lasting. Further studies based on real interactive experiences with mobile devices is advisable before it can be recommended for widespread use by HCP.

Identification of data elements for blood gas analysis dataset: a base for developing registries and artificial intelligence-based systems.

BACKGROUND: One of the challenging decision-making tasks in healthcare centers is the interpretation of blood gas tests. One of the most effective assisting approaches for the interpretation of blood gas analysis (BGA) can be artificial intelligence (AI)-based decision support systems. A primary step to develop intelligent systems is to determine information requirements and automated data input for the secondary analyses. Datasets can help the automated data input from dispersed information systems. Therefore, the current study aimed to identify the data elements required for supporting BGA as a dataset. MATERIALS AND METHODS: This cross-sectional descriptive study was conducted in Nemazee Hospital, Shiraz, Iran. A combination of literature review, experts' consensus, and the Delphi technique was used to develop the dataset. A review of the literature was performed on electronic databases to find the dataset for BGA. An expert panel was formed to discuss on, add, or remove the data elements extracted through searching the literature. Delphi technique was used to reach consensus and validate the draft dataset. RESULTS: The data elements of the BGA dataset were categorized into ten categories, namely personal information, admission details, present illnesses, past medical history, social status, physical examination, paraclinical investigation, blood gas parameter, sequential organ failure assessment (SOFA) score, and sampling technique errors. Overall, 313 data elements, including 172 mandatory and 141 optional data elements were confirmed by the experts for being included in the dataset. CONCLUSIONS: We proposed a dataset as a base for registries and AI-based systems to assist BGA. It helps the storage of accurate and comprehensive data, as well as integrating them with other information systems. As a result, high-quality care is provided and clinical decision-making is improved.

The Effect of Short Messaging System-Based Feedback on Physicians' Head CT Scan Ordering Behavior in Neurology and Neurosurgery Departments.

Short messaging system (SMS) works as one of the most popular strategies for physicians' behavior change via sending feedback and reminder messages. One of the areas in which SMS feedback can be effective on physicians' behavior is CT scan ordering. This study investigates the effect of mobile phone SMS feedback on residents' head CT scan ordering at a general teaching hospital in Iran. Through a three-month before-after experimental study, an intervention was conducted, and the CT scans ordered by an individual resident were evaluated every two weeks. Consequently, personal SMS-based feedback was provided to the residents, and the rate of CT per patient in the two phases of the study was analyzed. The mean CT scan ordered per patient decreased from 1.98 ± 1.09 to 1.74 ± 1.45, and this decrease was insignificant (P = 0.106). SMS-based feedback can reduce head CT scan ordering among residents; whereas this decline was not significant further studies are required to investigate its effectiveness.

Exploring the Influence of Users' Characteristics in Continuance Intention to Use Electronic Medical Records (EMR): Extending the Expectation Confirmation Model (ECM).

Even though the "user characteristics" (UC) can influence "acceptance" and "the continuance intention to use" of information systems such as electronic medical records (EMR), the effect of UC has not been adequately evaluated in post-adoption models. This study seeks to examine the effect of UC on post-usage of EMR using the expectation confirmation model (ECM). A total of 450 questionnaires was collected by a survey to extend ECM by integrating UC using structural equation modeling (SEM). Data were analyzed using LISREL through confirmatory factor analysis. A path analysis test was also performed to fit and confirm the model fit. The UC affects the "confirmation of expectations" directly and the "continuance intention to use" indirectly. The findings of the present study can provide a new path for further research on the extending of the ECM model. Moreover, end users' characteristics should be considered in the preparation and training phases of EMR implementation.

Effectiveness of Clinical Decision Support Systems on the Appropriate Use of Imaging for Central Nervous System Injuries: A Systematic Review.

BACKGROUND: One of the best practices for timely and efficient diagnoses of central nervous system (CNS) trauma and complex diseases is imaging. However, rates of imaging for CNS are high and impose a lot of costs to health care facilities in addition to exposing patients with negative impact of ionizing radiation. OBJECTIVES: This study aimed to systematically review the effects and features of clinical decision support systems (CDSSs) for the appropriate use of imaging for CNS injuries. METHOD: We searched MEDLINE, SCOPUS, Web of Science, and Cochrane without time period restriction. We included experimental and quasiexperimental studies that assessed the effectiveness of CDSSs designed for the appropriate use of imaging for CNS injuries in any clinical setting, including primary, emergency, and specialist care. The outcomes were categorized based on imaging-related, physician-related, and patient-related groups. RESULT: A total of 3,223 records were identified through the online literature search. Of the 55 potential papers for the full-text review, 11 eligible studies were included. Reduction of CNS imaging proportion varied from 2.6 to 40% among the included studies. Physician-related outcomes, including guideline adherence, diagnostic yield, and knowledge, were reported in five studies, and all demonstrated positive impact of CDSSs. Four studies had addressed patient-related outcomes, including missed or delayed diagnosis, as well as length of stay. These studies reported a very low rate of missed diagnosis due to the cancellation of computed tomography (CT) examine according to the CDSS recommendations. CONCLUSION: This systematic review reports that CDSSs decrease the utilization of CNS CT scan, while increasing physicians' adherence to the rules. However, the possible harm of CDSSs to patients was not well addressed by the included studies and needs additional investigation. The actual effect of CDSSs on appropriate imaging would be realized when the saved cost of examinations is compared with the cost of missed diagnosis.

Laboratory test ordering in inpatient hospitals: a systematic review on the effects and features of clinical decision support systems.

BACKGROUND: Studies have revealed inappropriate laboratory testing as a source of waste. This review aimed at evaluating the effects and features of CDSSs on physicians' appropriate laboratory test ordering in inpatient hospitals. METHOD: Medline through PubMed, SCOPUS, Web of Science, and Cochrane were queried without any time period restriction. Studies using CDSSs as an intervention to improve laboratory test ordering as the primary aim were included. The study populations in the included studies were laboratory tests, physicians ordering laboratory tests, or the patients for whom laboratory tests were ordered. The included papers were evaluated for their outcomes related to the effect of CDSSs which were categorized based on the outcomes related to tests, physician, and patients. The primary outcome measures were the number and cost of the ordered laboratory tests. The instrument from The National Heart Lung and Blood Institute (NIH) was used to assess the quality of the included studies. Moreover, we applied a checklist for assessing the quality and features of the CDSSs presented in the included studies. A narrative synthesis was used to describe and compare the designs and the results of included studies. RESULT: Sixteen studies met the inclusion criteria. Most studies were conducted based on a quasi-experimental design. The results showed improvement in laboratory test-related outcomes (e.g. proportion and cost of tests) and also physician-related outcomes (e.g. guideline adherence and orders cancellation). Patient-related outcomes (e.g. length of stay and mortality rate) were not well investigated in the included studies. In addition, the evidence about applying CDSS as a decision aid for interpreting laboratory results was rare. CONCLUSION: CDSSs increase appropriate test ordering in hospitals through eliminating redundant test orders and enhancing evidence-based practice. Appropriate testing and cost saving were both affected by the CDSSs. However, the evidence is limited about the effects of laboratory test CDSSs on patient-related outcomes.

Technical requirements framework of hospital information systems: design and evaluation.

BACKGROUND: Implementing the health information system (HIS) is more complex and costly than implementing other information systems. The present study was conducted to design and evaluate technical requirements for the HIS. METHODS: The present study was conducted in 2016 by determining technical requirements for the HIS using the Delphi technique and then evaluating this system using a checklist based on the approved requirements. RESULTS: The first part of the study designed a 73-item final list of technical requirements for the HIS in four domains, i.e. communication service, system architecture, security service and system response time. The evaluation results obtained in the second part showed that communication service was met in 63.8% of the HIS programs, system architecture in 65.5%, security service in 72.4% and system response time in 76.3%. CONCLUSIONS: A technical evaluation tool was designed and used to select and evaluate the HIS. The evaluation results suggested the study HIS was poorer in terms of communication service and system architecture than in the other two dimensions.

Designing and evaluating functional laboratory information system requirements integrated to hospital information systems.

RATIONALE, AIMS, AND OBJECTIVES: Laboratory information sub-systems play an important role in diagnosis and treatment of patients. This study aimed to determine functional requirements of users and assess the existence of these requirements in the laboratory information system. METHOD: This descriptive cross-sectional study was conducted in 2016 in two phases. The first phase was done through three stages. First, based on an unsystematic review of related literature, an outline of functional laboratory information system requirements was identified. In the second stage, these requirements were identified in group meetings in the form of a semi-structured questionnaire and given to experts. Then, modified Delphi technique was used to reach agreement on each item. Then, based on experts' comments, the final version of the questionnaire was presented including 61 closed-ended items using Likert scale and an open-ended item. It was surveyed by 50 experts using Delphi technique. Responses were scored, and the requirements whose mean final score was 3 and above were finally confirmed. In the second phase, based on the confirmed requirements, a checklist comprising 68 requirements was prepared and adopted hospital information systems were evaluated through researcher observation. Data were analysed using descriptive statistics. RESULTS: The final list of functional laboratory information system requirements was prepared with 68 items. The results of the evaluation revealed that confirmed requirements existed in 58.8% of hospital information systems. CONCLUSION: Laboratory information system requirements were designed with 68 items. Evaluation results showed that the systems were moderate in terms of compliance with the requirements.

Registry Data Coordinator (RDC): a Proper Accessible Strategy for Improving Road Traffic Injury (RTI) Hospital Based Trauma Registry Systems in Developing Countries and Low Income Countries.

INTRODUCTION: Evidence suggested that a significant level of trauma mortality can be prevented using registry system. AIM: This study aimed to improve Kashan Hospital Based Trauma Registry System (KHBTRS) for Road Traffic Injury (RTI). MATERIAL AND METHODS: After conducting focus group discussion absence of minimum data set (MDS) and poor data collection process (DCP) were identified as main problems for KHBTRS- RTI. Proposed MDS were surveyed by 20 experts of trauma research center of throughout the Iran. Then approved MDS applied for trauma registry system data base in form of SQL. DCP were reform from prospective data collection (review of medical record) to concurrent (through the interview) approach. RESULTS: Most of participants for MDS approval belonged to clinical group 13(65%). 146 MDS in eighteen main categories were proposed for RTI. The maximum score for each MDS main categories were attributed to body parts injured 220 (100%) and patient vital signs 139 (99.29%) respectively. Pilot testing of KHBTRS- RTI database of 50 (50%) riders indicated fully completeness 50 (100%) for concurrent approach. It was concluded that based on experts' viewpoints MDS relating to injury nature and place of occurrence have more priority in comparisons to MDS relating to causes of injury. It may attribute to health care providers focus on clinical care and treatment. CONCLUSION: It was concluded that based on experts' viewpoints MDS relating to injury nature and place of occurrence have more priority in comparisons to MDS relating to RTI prevention; it may attribute to health care providers focus on clinical care and treatment. To develop injury interventions based on given data, recruitment of professionals as registry data coordinator with specific job description to collect and advocacy of injury external causes data seems imperative.

Task-specific usability requirements of electronic medical records systems: Lessons learned from a national survey of end-users.

BACKGROUND: There are various approaches to evaluating the usability of electronic medical record (EMR) systems. User perspectives are an integral part of evaluation. Usability evaluations efficiently and effectively contribute to user-centered design and supports tasks and increase user satisfaction. This study determined the main usability requirements for EMRs by means of an end-user survey. METHOD: A mixed-method strategy was conducted in three phases. A qualitative approach was employed to collect and formulate EMR usability requirements using the focus group method and the modified Delphi technique. Classic Delphi technique was used to evaluate the proposed requirements among 380 end-users in Iran. RESULTS: The final list of EMR usability requirements was verified and included 163 requirements divided into nine groups. The highest rates of end-user agreement relate to EMR visual clarity (3.65 ± 0.61), fault tolerance (3.58 ± 0.56), and suitability for learning (3.55 ± 0.54). The lowest end-user agreement was for auditory presentation (3.18 ± 0.69). CONCLUSION: The highest and lowest agreement among end-users was for visual clarity and auditory presentation by EMRs, respectively. This suggests that user priorities in determination of EMR usability and their understanding of the importance of the types of individual tasks and context characteristics differ.

CT Utilization: A Case Study in Iran based on ACR Appropriateness Criteria.

Lue to the importance ot controlling healthcare costs and appropriate utiliza- tion of imaging, this study evaluates CT scan utilization based on the ACR appropriateness criteria in patients at Kashan University of Medical Sciences Tertiary Care University Hospital (KAUMS-TCUH) in Kashan, Iran. Of CT scans performed, imaging proce- dures were rated as inappropriate (9.1%), may be appropriate (11.9%), and appropriate (78.9%). Findings revealed that the highest rates for appropriate and inappropriate requests pertained to trauma (101, 87.8%) and ataxia (8, 34.8%) patients. Findings demonstrated that CT scan utilization is not appropriate in Kashan. Of the total rates of CT scans, almost one tenth are in the inappropriate and may be appropriate groups. This suggests immediate actions to reduce the rates. For effective intervention based on the problematic area, a utilization commit- tee for resources should be established to regularly direct the CT scan utilization.

A review on laboratory tests' utilization: A trigger for cutting costs and quality improvement in health care settings.

BACKGROUND: Considering the role of laboratory tests as a central part of controlling health expenditure, this study intends to investigate laboratory tests overutilization in Iran to pave the way for future interventions. METHODS: Inappropriate laboratory utilization was reviewed in a cross-sectional survey through the retrospective analysis of 384 medical records at a tertiary center. To pave the way for future intervention, overutilization tests were classified into two categories, inappropriate and inefficient, and then they were analyzed. Frequency analysis was used to analysis patient's age, gender, hospital wards, length of stay, and diagnosis as well as inappropriate test and inefficient tests. RESULTS: A total of 143 (1.50 %) of the tests were inefficient and was ordered due to laboratory errors including hemolysis, inefficient sampling, or absurd results. 2522 (26.40%) of the tests were inappropriate and stem from failure to meet medical/clinical appropriateness criteria. CONCLUSION: Whereas, inappropriate test ordering was more frequent than inefficient tests, the initial improvement strategy should focus on physicians' test ordering behavior through conducting proper teaching strategies, ongoing audit and educational feedback, implementing health information technology tools and employing laboratory practice guidelines (LPGs) and testing algorithms. Conducting continuous quality improvement cycle for laboratory services and training of personnel involved in blood sampling is recommended for inefficient tests.

Nursing Information Systems Requirements: A Milestone for Patient Outcome and Patient Safety Improvement.

Considering the integral role of understanding users' requirements in information system success, this research aimed to determine functional requirements of nursing information systems through a national survey. Delphi technique method was applied to conduct this study through three phases: focus group method modified Delphi technique and classic Delphi technique. A cross-sectional study was conducted to evaluate the proposed requirements within 15 general hospitals in Iran. Forty-three of 76 approved requirements were clinical, and 33 were administrative ones. Nurses' mean agreements for clinical requirements were higher than those of administrative requirements; minimum and maximum means of clinical requirements were 3.3 and 3.88, respectively. Minimum and maximum means of administrative requirements were 3.1 and 3.47, respectively. Research findings indicated that those information system requirements that support nurses in doing tasks including direct care, medicine prescription, patient treatment management, and patient safety have been the target of special attention. As nurses' requirements deal directly with patient outcome and patient safety, nursing information systems requirements should not only address automation but also nurses' tasks and work processes based on work analysis.

Medical universities educational and research online services: benchmarking universities' website towards e-government.

BACKGROUND: Websites as one of the initial steps towards an e-government adoption do facilitate delivery of online and customer-oriented services. In this study we intended to investigate the role of the websites of medical universities in providing educational and research services following the E-government maturity model in the Iranian universities. METHODS: This descriptive and cross- sectional study was conducted through content analysis and benchmarking the websites in 2012. The research population included the entire medical university website (37). Delivery of educational and research services through these university websites including information, interaction, transaction, and Integration were investigated using a checklist. The data were then analyzed by means of descriptive statistics and using SPSS software. RESULTS: Level of educational and research services by websites of the medical universities type I and II was evaluated medium as 1.99 and 1.89, respectively. All the universities gained a mean score of 1 out of 3 in terms of integration of educational and research services. CONCLUSIONS: Results of the study indicated that Iranian universities have passed information and interaction stages, but they have not made much progress in transaction and integration stages. Failure to adapt to e-government in Iranian medical universities in which limiting factors such as users' e-literacy, access to the internet and ICT infrastructure are not so crucial as in other organizations, suggest that e-government realization goes beyond technical challenges.

The Effect of Educational Intervention on Medical Diagnosis Recording among Residents.

INTRODUCTION: Studies indicate that using interventions including education may improve medical record documentation and decrease incomplete files. Since physicians play a crucial role in medical record documentation, the researchers intend to examine the effect of educational intervention on physicians' performance and knowledge about principles of medical diagnosis recording among residents in Hormozgan University of Medical Sciences(HUMS). METHODS: This quasi-experimental study was conducted in 2010 on 40 specialty residents (from internal medicine, obstetrics and gynecology, pediatrics, anesthesiology and surgery specialties) in Hormozgan University of Medical Sciences. During a workshop, guidelines for recording diagnostic information related to given specialty were taught. Before and after the intervention, five medical records from each resident were selected to assess physician performance about chart documentation. Using a questionnaire, physicians' knowledge was investigated before and after intervention. Data were analyzed through one-way ANOVA test. RESULTS: Change in physicians' knowledge before and after education was not statistically significant (p = 0.15). Residents' behavior did not have statistically significant changes during three phases of the study. CONCLUSION: Diversity of related factors which contributes to the quality of documentation compels portfolio of strategies to enhance medical charting. Employing combination of best practice efforts including educating physicians from the beginning of internship and applying targeted strategy focus on problematic areas and existing gap may enhance physicians' behavior about chart documentation.