[Effectiveness of an assessment of computerised medical records in a university hospital]. / Efectividad de la evaluación de historias clínicas informatizadas en un hospital universitario.

OBJECTIVE: The objective of this study was to evaluate a sample of electronic medical records (EMR) that was sufficiently representative of the different areas of care in a university hospital, as well as to verify the effectiveness of an initial intervention through a second evaluation. METHODS: Medical records audits were performed in 2012 and 2013 by a blind peer review of random samples of care episodes, proportional to the activity of each clinical department, and with the same evaluation method being applied to all of them. RESULTS: More than 1,000 episodes of care were reviewed in the 2audits. A significant improvement was found in hospital admissions (P=.000) in all the sections of the EMR analysed (P=.002), and was especially significant for the reason for consultation, for which its completion increased by 8.5% (p<.05), and also in the sections of the current process record (7.1%), physical examination (4.7%), allergies (3.9%), and clinical course (3.6%). The assessment of the discharge report, as a whole, showed an improvement (P=.001). In outpatient follow-up visits, a significant positive improvement was observed in the 4sections evaluated (P<.05), and also overall (P=.000). CONCLUSIONS: According to study conditions, the dissemination of the results was effective in improving the quality of the EMR. The results have made it possible to implement actions to review the work processes in certain departments, and also the partial redesign of the interface on being a reproducible methodology accepted by the organisation.

Is the incidence of optic neuritis rising? Evidence from an epidemiological study in Barcelona (Spain), 2008-2012.

It is currently believed that the incidence rate of optic neuritis (ON) ranges between 0.56 and 5.1 cases per 100,000 person-years. However, since these figures were generated, they have not been updated and there are suggestions that the incidence of ON is on the rise. When designing new therapies and clinical trials for ON, and to improve the management this disease, it is important to have accurate epidemiological data. Thus, we set out to obtain the prevalence and incidence rates of ON in Barcelona (Spain) from 2008 to 2012, by a retrospective evaluation of electronic hospital records at the Hospital Clinic of Barcelona (population of 300,000 in the catchment area) matching the following ICD-9-CM codes as search terms: 377.3-optic neuritis; 377.30-optic neuritis, unspecific; 377.31-optic papillitis; 377.32-retrobulbar neuritis, acute; 377.39-other optic neuritis and "optic neuropathy". Demographic and clinical data were collected from records with a confirmed diagnosis of ON, including cases of idiopathic ON, multiple sclerosis, neuromyelitis optica and CRION. The prevalence of acute ON on 31 December 2012 was 2.75 cases per 100,000 people. The mean annual prevalence of acute ON during the 2008-2012 period was 7.87 cases per 100,000 person-year and the mean annual incidence rate was 5.36 cases per 100,000 person-years. The incidence of ON in Barcelona during 2008-2012 was higher than previously reported. This increase may reflect the evolution of diagnostic criteria, the use of a referral-center approach instead of a population-based approach, increased awareness of demyelinating diseases, latitude-related factors and possibly a true increase in its incidence.