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Electronic Health Record

Author: Alexander Scarlat, MD
Publisher: CRC Press
ISBN: 1466559225
Size: 24.26 MB
Format: PDF, Kindle
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An accessible primer, Electronic Health Record: A Systems Analysis of the Medications Domain introduces the tools and methodology of Structured Systems Analysis as well as the nuances of the Medications domain. The first part of the book provides a top-down decomposition along two main paths: data in motion—workflows, processes, activities, and tasks in parallel to the analysis of data at rest—database structures, conceptual, logical models, and entities relationship diagrams. Structured systems analysis methodology and tools are applied to: electronic prescription, computerized physician order entry, drug dispensation, medication administration, and clinical decision support. Assuming no previous clinical and/or informatics knowledge, the book supplies a comprehensive view of the EHR/EMR with dedicated chapters on: user interface considerations, reporting requirements, and standards and vocabularies for meaningful use. Containing clear language and more than 170 figures and 100 review questions with answers—this book is a great companion for Healthcare IT professionals and an ideal resource for clinical informatics students. Praise for the book: ... a common sense guide to this new world of informatics ... should prove invaluable to the clinician making his/her way past the commercial hype into the realm of true understanding of the systems of medical informatics. ... strongly recommended ... . —William F. Bria MD, CMIO Shriners Hospitals for Children, President of the Board, Association of Medical Directors of Information Systems Finally, here’s a textbook that the market and the industry have been looking for. The author has captured the details of the information flows involved in the EHR while processing an order or prescription from inception to completion. —Joseph T. Finn, RPh, MBA ... a thoughtful and well-constructed manual to understanding and incorporating the complex and many-sided aspects of medication concepts ... a clear and accessible entry to this challenging topic. —Don Martin, Managing Consultant ... encompasses high-value, high-volume therapeutic transactions of indescribable complexity that touch nearly every licensed professional in a hospital ... I’m hoping the vendors of my own hospital’s systems take its recommendations to heart. —Mr. HIStalk, Healthcare IT Blogger .... a very useful guide ... provides the necessary detail that is often missing in many books... very useful in health informatics education at universities and courses within community colleges. —Jane M. Brokel, PhD, RN ... a welcome and valuable addition to the toolkit for IT professionals and clinicians participating in the design or implementation of EHR systems. —Christine Greifzu, RN-BC, MBA, MSIS

Better Ehr

Author: Jiajie Zhang (Professor of biomedical informatics)
Publisher:
ISBN: 9780692262962
Size: 54.96 MB
Format: PDF, ePub
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Electronic Health Records (EHR) offer great potential to increase healthcare efficiency, improve patient safety, and reduce health costs. The adoption of EHRs among office-based physicians in the US has increased from 20% ten years ago to over 80% in 2014. Among acute care hospitals in US, the adoption rate today is approaching 100%. Finding relevant patient information in electronic health records' (EHRs) large datasets is difficult, especially when organized only by data type and time. Automated clinical summarization creates condition-specific displays, promising improved clinician efficiency. However, automated summarization requires new kinds of clinical knowledge (e.g., problem-medication relationships).

Capturing Social And Behavioral Domains In Electronic Health Records

Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309301130
Size: 28.19 MB
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Substantial empirical evidence of the contribution of social and behavioral factors to functional status and the onset and progression of disease has accumulated over the past few decades. Electronic health records (EHRs) provide crucial information to providers treating individual patients, to health systems, including public health officials, about the health of populations, and to researchers about the determinants of health and the effectiveness of treatment. Inclusion of social and behavioral health domains in EHRs is vital to all three uses. The Health Information Technology for Economic and Clinical Health Act and the Patient Protection and Affordable Care Act place new importance on the widespread adoption and meaningful use of EHRs. "Meaningful use" in a health information technology context refers to the use of EHRs and related technology within a health care organization to achieve specified objectives. Achieving meaningful use also helps determine whether an organization can receive payments from the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program. Capturing Social and Behavioral Domains in Electronic Health Records is the first phase of a two-phase study to identify domains and measures that capture the social determinants of health to inform the development of recommendations for meaningful use of EHRs. This report identifies specific domains to be considered by the Office of the National Coordinator, specifies criteria that should be used in deciding which domains should be included, identifies core social and behavioral domains to be included in all EHRs, and identifies any domains that should be included for specific populations or settings defined by age, socioeconomic status, race/ethnicity, disease, or other characteristics.

Capturing Social And Behavioral Domains And Measures In Electronic Health Records

Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309312450
Size: 35.96 MB
Format: PDF
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Determinants of health - like physical activity levels and living conditions - have traditionally been the concern of public health and have not been linked closely to clinical practice. However, if standardized social and behavioral data can be incorporated into patient electronic health records (EHRs), those data can provide crucial information about factors that influence health and the effectiveness of treatment. Such information is useful for diagnosis, treatment choices, policy, health care system design, and innovations to improve health outcomes and reduce health care costs. Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 identifies domains and measures that capture the social determinants of health to inform the development of recommendations for the meaningful use of EHRs. This report is the second part of a two-part study. The Phase 1 report identified 17 domains for inclusion in EHRs. This report pinpoints 12 measures related to 11 of the initial domains and considers the implications of incorporating them into all EHRs. This book includes three chapters from the Phase 1 report in addition to the new Phase 2 material. Standardized use of EHRs that include social and behavioral domains could provide better patient care, improve population health, and enable more informative research. The recommendations of Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 will provide valuable information on which to base problem identification, clinical diagnoses, patient treatment, outcomes assessment, and population health measurement.

Systems Practices For The Care Of Socially At Risk Populations

Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309391970
Size: 58.26 MB
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The Centers for Medicare & Medicaid Services (CMS) have been moving from volume-based, fee-for-service payment to value-based payment (VBP), which aims to improve health care quality, health outcomes, and patient care experiences, while also controlling costs. Since the passage of the Patient Protection and Affordable Care Act of 2010, CMS has implemented a variety of VBP strategies, including incentive programs and risk-based alternative payment models. Early evidence from these programs raised concerns about potential unintended consequences for health equity. Specifically, emerging evidence suggests that providers disproportionately serving patients with social risk factors for poor health outcomes (e.g., individuals with low socioeconomic position, racial and ethnic minorities, gender and sexual minorities, socially isolated persons, and individuals residing in disadvantaged neighborhoods) may be more likely to fare poorly on quality rankings and to receive financial penalties, and less likely to receive financial rewards. The drivers of these disparities are poorly understood, and differences in interpretation have led to divergent concerns about the potential effect of VBP on health equity. Some suggest that underlying differences in patient characteristics that are out of the control of providers lead to differences in health outcomes. At the same time, others are concerned that differences in outcomes between providers serving socially at-risk populations and providers serving the general population reflect disparities in the provision of health care. Systems Practices for the Care of Socially At-Risk Populations seeks to better distinguish the drivers of variations in performance among providers disproportionately serving socially at-risk populations and identifies methods to account for social risk factors in Medicare payment programs. This report identifies best practices of high-performing hospitals, health plans, and other providers that serve disproportionately higher shares of socioeconomically disadvantaged populations and compares those best practices of low-performing providers serving similar patient populations. It is the second in a series of five brief reports that aim to inform the Office of the Assistant Secretary of Planning and Evaluation (ASPE) analyses that account for social risk factors in Medicare payment programs mandated through the Improving Medicare Post-Acute Care Transformation (IMPACT) Act.

Engineering A Learning Healthcare System

Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309120640
Size: 59.41 MB
Format: PDF
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Improving our nation's healthcare system is a challenge which, because of its scale and complexity, requires a creative approach and input from many different fields of expertise. Lessons from engineering have the potential to improve both the efficiency and quality of healthcare delivery. The fundamental notion of a high-performing healthcare system--one that increasingly is more effective, more efficient, safer, and higher quality--is rooted in continuous improvement principles that medicine shares with engineering. As part of its Learning Health System series of workshops, the Institute of Medicine's Roundtable on Value and Science-Driven Health Care and the National Academy of Engineering, hosted a workshop on lessons from systems and operations engineering that could be applied to health care. Building on previous work done in this area the workshop convened leading engineering practitioners, health professionals, and scholars to explore how the field might learn from and apply systems engineering principles in the design of a learning healthcare system. Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary focuses on current major healthcare system challenges and what the field of engineering has to offer in the redesign of the system toward a learning healthcare system.

Issues In Clinical Medicine Research And Practice 2013 Edition

Author:
Publisher: ScholarlyEditions
ISBN: 1490108963
Size: 47.97 MB
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Issues in Clinical Medicine Research and Practice: 2013 Edition is a ScholarlyEditions™ book that delivers timely, authoritative, and comprehensive information about Clinical Endocrinology. The editors have built Issues in Clinical Medicine Research and Practice: 2013 Edition on the vast information databases of ScholarlyNews.™ You can expect the information about Clinical Endocrinology in this book to be deeper than what you can access anywhere else, as well as consistently reliable, authoritative, informed, and relevant. The content of Issues in Clinical Medicine Research and Practice: 2013 Edition has been produced by the world’s leading scientists, engineers, analysts, research institutions, and companies. All of the content is from peer-reviewed sources, and all of it is written, assembled, and edited by the editors at ScholarlyEditions™ and available exclusively from us. You now have a source you can cite with authority, confidence, and credibility. More information is available at http://www.ScholarlyEditions.com/.

Health It And Patient Safety

Author: Committee on Patient Safety and Health Information Technology
Publisher: National Academies Press
ISBN: 0309221129
Size: 56.17 MB
Format: PDF, ePub, Mobi
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IOM's 1999 landmark study To Err is Human estimated that between 44,000 and 98,000 lives are lost every year due to medical errors. This call to action has led to a number of efforts to reduce errors and provide safe and effective health care. Information technology (IT) has been identified as a way to enhance the safety and effectiveness of care. In an effort to catalyze its implementation, the U.S. government has invested billions of dollars toward the development and meaningful use of effective health IT. Designed and properly applied, health IT can be a positive transformative force for delivering safe health care, particularly with computerized prescribing and medication safety. However, if it is designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care. Poorly designed IT can introduce risks that may lead to unsafe conditions, serious injury, or even death. Poor human-computer interactions could result in wrong dosing decisions and wrong diagnoses. Safe implementation of health IT is a complex, dynamic process that requires a shared responsibility between vendors and health care organizations. Health IT and Patient Safety makes recommendations for developing a framework for patient safety and health IT. This book focuses on finding ways to mitigate the risks of health IT-assisted care and identifies areas of concern so that the nation is in a better position to realize the potential benefits of health IT. Health IT and Patient Safety is both comprehensive and specific in terms of recommended options and opportunities for public and private interventions that may improve the safety of care that incorporates the use of health IT. This book will be of interest to the health IT industry, the federal government, healthcare providers and other users of health IT, and patient advocacy groups.

Secondary Analysis Of Electronic Health Records

Author: MIT Critical Data
Publisher: Springer
ISBN: 3319437429
Size: 15.84 MB
Format: PDF, Kindle
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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.

Foundations Of Health Information Management

Author: Nadinia A. Davis
Publisher: Elsevier Health Sciences
ISBN: 0323389759
Size: 35.83 MB
Format: PDF, Kindle
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Foundations of Health Information Management, 4th Edition is an absolute must for any student beginning a career in HIM. Balancing comprehensive coverage with an engaging, easy-to-understand tone, this text focuses on healthcare delivery systems, electronic health records, and the processing, maintenance, and analysis of health information to present a realistic and practical view of technology and trends in healthcare. It prepares you for the role of a Registered Health Information Technician who not only files and keeps accurate records, but serves as a healthcare analyst who translates data into useful, quality information that can control costs and further research. With new SimChart and SimChart for the Medical Office samples, the new 2014 AHIMA outcome-based competencies, and more exercises, this fourth edition puts you in a position to succeed on the RHIT certification exam. Clear writing style and easy reading level makes reading and studying more time-efficient, and is ideal for two-year associate degree HIM programs and career schools. Chapter learning objectives are tied to the American Health Information Management Association's (AHIMA) HIM domains and subdomains to allow instructors to teach to the credentialing exam — and prepare you for the exam. Separate legal chapter covers HIPAA privacy regulations and emphasizes the importance of HIPAA compliance in today’s healthcare system. Statistics chapter gives new students a foundation for learning. Four-color design and illustrations make content more appealing and easier to learn. Exercises at the end of every main section in each chapter encourage you to review and apply key concepts. Career Tip and Professional Profile boxes give you a broader view of the field and show you the many career options you have upon graduation and certification. Chapter summaries and reviews allow for easy review of each chapter’s main concepts. Robust appendices, including sample paper records, electronic documentation, and demonstration of Microsoft Excel, equip you with all the extras you need to enter the HIM world. NEW! Content mapped to 2014 AHIMA CEE competencies and domains so you can prepare for the current health information environment and the RHIT exam. NEW! SimChart and SimChart for the Medical Office samples feature screenshots from EHRs to demonstrate electronic medical records in use. NEW! More exercises give you additional opportunities to practice your knowledge of material. NEW! AHIMA competency mapping included in the front of book to provide instructors and students with instant access to the AHIMA domains and competencies needed to prepare for the RHIT exam. NEW! Classroom handouts can be used in the classroom or as homework, and include a variety of exercises.