Key Capabilities of an Electronic Health Record System


Book Description

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.




Registries for Evaluating Patient Outcomes


Book Description

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.




Aspects of Electronic Health Record Systems


Book Description

As adoption of Electronic Health Record Systems (EHR-Ss) shifts from early adopters to mainstream, an increasingly large group of decision makers must assess what they want from EHR-Ss and how to go about making their choices. The purpose of this book is to inform that decision. This book explains typical needs of a variety of stakeholders, describes current and imminent technologies, and assesses the available evidence regarding issues in implementing and using EHR-Ss. Divided into four important sections--Needs, Current State, Technology, and Going Forward--the book provides the background and general notions regarding the EHRS and lays out the framework; delves into the historical review; presents a high-level view of EHR systems, focused on the needs of different stakeholders in the health care and the health enterprise; offers practical views of existing systems and current (and short-term future) issues in specifying a EHR system and deciding how to approach the institution of such a system; deals with technology issues, from front- to back-end; and describes where we are and where we should be going with EHR systems. Designed for use by chief information officers, chief medical informatics officers, medical liaisons to hospital systems, private practitioners, and business managers at academic and non-academic hospitals, care management organizations, and practices. The book could be used in any medical or health informatics course, at any level (undergrad, fellowship, MBA).




Electronic Health Records and Medical Big Data


Book Description

This book helps readers gain an in-depth understanding of electronic health record (EHR) systems, medical big data, and the regulations that govern them. It analyzes both the shortcomings and benefits of EHR systems, exploring the law's response to the creation of these systems, highlighting gaps in the current legal framework, and developing detailed recommendations for regulatory, policy, and technological improvements. Electronic Health Records and Medical Big Data addresses not only privacy and security concerns but also other important challenges, such as those related to data quality and data analysis. In addition, the author formulates a large body of recommendations to improve the technology's safety, security, and efficacy for both clinical and secondary (such as research) uses of medical data.




Electronic Health Record


Book Description

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




Capturing Social and Behavioral Domains and Measures in Electronic Health Records


Book Description

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.




Electronic Health Record


Book Description

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 tas




Electronic Health Records


Book Description

Resource added for the Health Information Technology program 105301.




The Computer-Based Patient Record


Book Description

Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.




Taking Action Against Clinician Burnout


Book Description

Patient-centered, high-quality health care relies on the well-being, health, and safety of health care clinicians. However, alarmingly high rates of clinician burnout in the United States are detrimental to the quality of care being provided, harmful to individuals in the workforce, and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organization, and culture of health care. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being builds upon two groundbreaking reports from the past twenty years, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, which both called attention to the issues around patient safety and quality of care. This report explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.