Electronic Medical Records

This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable results that cannot be replicated. Even randomized controlled trials (RCTs), the traditional gold standards of the research reliability hierarchy, are not without limitations. They can be costly, labor intensive, and slow, and can return results that are seldom generalizable to every patient population. Furthermore, many pertinent but unresolved clinical and medical systems issues do not seem to have attracted the interest of the research enterprise, which has come to focus instead on cellular and molecular investigations and single-agent (e.g., a drug or device) effects. For clinicians, the end result is a bit of a “data desert” when it comes to making decisions. The new research infrastructure proposed in this book will help the medical profession to make ethically sound and well informed decisions for their patients.

Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.

This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

Clinical Infomation Systems are increasingly important in Medical Practice. This work is a two-part book detailing the importance, selection and implementation of information systems in the health care setting. Volume One discusses the technical, organizational, clinical and administrative issues pertaining to EMR implementation. Highlighted topics include: infrastructure of the electronic patient records for administrators and clinicians, understanding processes and outcomes, and preparing for an EMR. The second workbook is filled with sample charts and questions, guiding the reader through the actual EMR implementation process.

Physician adoption of electronic medical records (EMRs) has become a national priority. It is said that EMRs have the potential to greatly improve patient care, to provide the data needed for more effective population management and quality assurance of both an individual practice’s patients and well as patients of large health care systems, and the potential to create efficiencies that allow physicians to provide this improved care at a far lower cost than at present. There is currently a strong U.S. government push for physicians to adopt EMR technology, with the Obama administration emphasizing the use of EMRs as an important part of the future of health care and urging widespread adoption of this technology by 2014. This timely book for the primary care community offers a concise and easy to read guide for implementing an EMR system. Organized in six sections, this invaluable title details the general state of the EMR landscape, covering the government’s incentive program, promises and pitfalls of EMR technology, issues related to standardization and the range of EMR vendors from which a provider can choose. Importantly, chapter two provides a detailed and highly instructional account of the experiences that a range of primary care providers have had in implementing EMR systems. Chapter three discusses how to effectively choose an EMR system, while chapters four and five cover all of the vital pre-implementation and implementation issues in establishing an EMR system in the primary care environment. Finally, chapter six discusses how to optimize and maintain a new EMR system to achieve the full cost savings desired. Concise, direct, but above all honest in recognizing the challenges in choosing and implementing an electronic health record in primary care, Electronic Medical Records: A Practical Guide for Primary Care has been written with the busy primary care physician in mind.

The straight scoop on choosing and implementing an electronic health records (EHR) system Doctors, nurses, and hospital and clinic administrators are interested in learning the best ways to implement and use an electronic health records system so that they can be shared across different health care settings via a network-connected information system. This helpful, plain-English guide provides need-to-know information on how to choose the right system, assure patients of the security of their records, and implement an EHR in such a way that it causes minimal disruption to the daily demands of a hospital or clinic. Offers a plain-English guide to the many electronic health records (EHR) systems from which to choose Authors are a duo of EHR experts who provide clear, easy-to-understand information on how to choose the right EHR system an implement it effectively Addresses the benefits of implementing an EHR system so that critical information (such as medication, allergies, medical history, lab results, radiology images, etc.) can be shared across different health care settings Discusses ways to talk to patients about the security of their electronic health records Electronic Health Records For Dummies walks you through all the necessary steps to successfully choose the right EHR system, keep it current, and use it effectively.

Discover How Electronic Health Records Are Built to Drive the Next Generation of Healthcare Delivery The increased role of IT in the healthcare sector has led to the coining of a new phrase "health informatics," which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks. This book provides an overview of different health informatics resources and artifacts that underlie the design and development of interoperable healthcare systems and applications. Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures compiles, for the first time, study and analysis results that EHR professionals previously had to gather from multiple sources. It benefits readers by giving them an understanding of what roles a particular healthcare standard, code, or framework plays in EHR design and overall IT-enabled healthcare services along with the issues involved. This book on Electronic Health Record: Offers the most comprehensive coverage of available EHR Standards including ISO, European Union Standards, and national initiatives by Sweden, the Netherlands, Canada, Australia, and many others Provides assessment of existing standards Includes a glossary of frequently used terms in the area of EHR Contains numerous diagrams and illustrations to facilitate comprehension Discusses security and reliability of data

Resource added for the Health Information Technology program 105301.