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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.
Resource added for the Health Information Technology program 105301.
This book provides innovative practical suggestions regarding the production and management of medical records that are designed to address the inconsistencies and errors that have been highlighted especially in relation to national eHealth programs. Challenges and lessons that have emerged from the use of clinical information and the design of medical records are discussed, and principles underpinning the implementation of health IT are critically examined. New trends in the use of clinical data are explored in depth, with analysis of issues relating to integration and sharing of patient information, data visualization, big data analytics, and the requirements of modern electronic health records. The spirit pervading the book is one of co-production, in which the needs of practitioners are taken into account from the outset. Readers will learn the basic concepts of how clinical information emanating from the doctor–patient relationship can be effectively integrated with genetic and environmental data and analyzed by complex algorithms with the goal of improving medical decision making and patient care. The book, written by European experts and researchers, will be of interest to all stakeholders in the field, including doctors, technicians, and policy makers.
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.
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.
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.
Unlike other available books on medical records--which focus on management of HIM departments--this one is especially designed for entry-level health information/medical record clerks. It orients learners to the essential step-by-step procedures for being a medical records clerk--from the importance of confidentiality to filing. KEY TOPICS Specific chapter topics cover the health information management department, number and filing methods, processing medical records, assembly and analysis of the medical record, physician incomplete area, confidentiality and release of information, and other medical record clerk functions. For directors, managers/supervisors of HIM departments in hospitals, physicians offices, and outpatient clinics; and also for use in hospitals, and for anyone maintaining medical records.
Part 1: Traditional Medical Records Organization and Management Procedures Chapter 1: History of Medical Records Administration Chapter 2: Role of Medical Records in Health Care Delivery Chapter 3: General Medical Records Standards and Policies Chapter 4: Legal Aspects of Medical Records and Electronic Health Records (EHRs) Chapter 5: Medical Audit Chapter 6: ICD-10 Revision, ICD-10CM and ICD-10 PCS Revision Chapter 7: Hospital Information System Chapter 8: How to Economize Health Service Expenditure Chapter 9: Organization and Management of the Medical Record Department Chapter 10: Medical Record Procedures Part 2: Design and Development of Hospital Information System (HIS) for Software Production Chapter 11: Computerization of the Medical Records Chapter 12: Challenges of the Health Care Delivery in 21st Century Chapter 13: Domain for Designing the Hospital Information System (HIS) Software Chapter 14: Designing the Hospital Ward Nursing Administrative Activities Chapter 15: Blood Transfusion Service Chapter 16: Pediatric Center Chapter 17: Diabetic Center Chapter 18: Dialysis Center Chapter 19: Dental Clinic Chapter 20: IVF (In Vitro Fertilization) Clinic Chapter 21: Occupational Health and Safety Chapter 22: Biomedical Equipment Maintenance Part 3: Development and Implementation of Electronic Health Records (EHR) Chapter 23: Perspective of Information Technology (IT) in Hospital Information System Chapter 24: Challenges in Hospital IT and Networking Design Chapter 25: Tips for Evaluation of Electronic Health Record Software Chapter 26: Roadmap for Successful Implementaion of EHR Chapter 27: Amalgamation of Manual Record (MR) with Electronic Health Records (EHRs) Chapter 28: Health Record Manager (HRM) Revolves around Patient as a Good Leader Chapter 29: Modern Trends and Issues of Developing Countries in Maintaining Medical Records Chapter 30: Health Information Management (HIM) Professionals Endurance in 21st Century Chapter 31: Implementation of Personal Health Record (PHR) Bibliography Appendix