...Kirkendol Definition of Terms People working with health information technology (HIT) systems must familiarize themselves with key terms to help them perform their assigned work tasks. The terms below help health care organizations to operate more accurately and efficiently. By applying these tools and resources, health care organizations and professionals provide better services and a continuum of care to their patients. Key terms include acronyms, such as AMR, CMR, CMS, CMS-1500, CPT, DRG, EPR, HL7, ICD-9, and UB-92. The following excerpt will translate and define these acronyms and describe the most important aspect of these key terms. Translation and Definition of Key Health Information Technology Terms SearchHealthIT (2011) describes an ambulatory medical record (AMR) as “an electronically stored file of a patient’s outpatient medical records, which includes all surgeries and care that do not involve being admitted to a hospital” (para. 1). Physicians and other medical professionals have access to a patient’s complete medical history. The article states the most important aspect of an AMR lies in the fact they only apply to medical procedures, which require an overnight or longer stay in the hospital. Ambulatory medical records only exist in non-hospital environments, such as physicians’ offices, urgent care clinics, and at-home medical care settings. A computerized medical record (CMR) stores health information and data about a patient in a computer....
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...15 a. Aggressive Implementation 16 b. High Costs 16 c. Labor Investment 17 d. Opportunity Cost 17 e. Impact on Researchers, Policymaker and Educators 18 V. Final Opinion 19 VI. Bibliography 22 VII. Appendix I 28 VIII. Appendix II 31 I. Advantages of EHRs In an effort to reign in rising health care costs and increased health care disparity and inequality in the U.S., former president George W. Bush doubled the funding for Health Care Information Technology to 100 million in 2005 (The White House). It was part of a larger plan to utilize latest information technology to standardize patient and health records, which despite spending 1.6 trillion dollars, attributed to 98,000 medically related errors in 2004. The plan was part of his campaign promise and was reiterated in his January 20, 2004 State of the Union address when, President Bush remarked, “by computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” Considering that the federal government is “one of the largest buyers of healthcare - in Medicare, Medicaid, the Community Health Centers program, the Federal Health Benefits program, Veterans medical care, and programs in...
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...Definition of terms Chinedu HCS/533 Health Information Systems AUGUST 25, 2014. Definition of terms This presentation will translate and define the following abbreviations: AMR, CMR, CMS, CMS-1500, CPT, DRG, EPR, HL7, ICD-9, and UB-92. Technology today has revolutionized the health care system, as technology evolves, so does the environment promoting quality care for those in need of it. AMR- An ambulatory medical record (AMR) is an electronically stored file of a patient’s outpatient medical records, which includes all surgeries and care that do not involve being admitted to a hospital. An AMR is similar to an electronic medical record (EMR), but while EMR’s keep track of inpatient care (surgeries and care that require spending overnight or longer in a hospital), AMRs only apply to medical procedures and cares that do not result in an overnight stay in a hospital or that are given in non-hospital settings such as urgent care clinics, physicians’ offices and at home medical care. AMRs are stored in electronic databases called ambulatory medical record systems that are accessible by doctors and other medical professionals. CMR- Computerized medical record is an electronic information system and keeps records of each individual patient’s health. Computerized medical records (CMR) provide a viable mechanism for implementing clinical governance. Computers are involved in all aspects of the clinical interaction-from consulting room to system-level use of large systems...
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...management of patient information is not new. Research into the implementation of health care information systems spans more than thirty years at a cost of millions of dollars (Zheng, McGrath, Hamilton, Tanner, White, Pohl, 2009). In spite of those costly efforts, patient records continue to be primarily paper-based. The Institute of Medicine (IOM) (1991) of the National Academy of Sciences recognized the magnitude of the problems associated with paper medical records systems and called for the adoption of computer-based patient records (CPR) or electronic medical records (EMR) as the standard for all patient records by the year 2001. EMR systems have been shown to have value in patient care; they are not widely used by clinicians in community-based practice. Although there are barriers to the productive use of EMR systems in primary care and there are situations in which such systems have failed, there are early adopters of this technology who have successfully implemented the systems and made them an integral part of their organizations. Gaining better understanding of the usefulness of EMR systems and how they might be broadly utilized and successfully implemented in the community-based practice environment requires further investigation. Identifying, analyzing, and understanding certain organizational factors that contribute to the use and acceptance of EMR among health care providers in ambulatory care, community-based settings will add to a presently insufficient body of knowledge...
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...Health Informatics and Healthcare Introduction Health informatics as defined by Shi and Singh 2015, as the application of information science to improve efficiency, accuracy, reliability of healthcare service, and inclusion of healthcare delivery. Healthcare informatics is becoming more complex than any other time in recent memory, the foundation needed to bolster device utilization and interoperability is more expanded, and there is even a more extensive scope of utilization to consider. As the populace ages, there is added pressure to provide patient care choices at home and in the community, implying that medical devices are getting to be a piece of a much bigger ecosystem spreading over the steadily developing continuum. This paper will analyze health informatics and discuss its benefits, trends, current issues, the impact health informatics in healthcare settings, and the role of health managers and the future. An interview will be conducted with a health professional to get their point of view of how health informatics have impacted their workplace, with further discussion of human resources, careers and the future. History The U.S. National Library of Medicine defines health informatics as a collaborative effort of designing, developing, adopting, and applying IT-based ideas in healthcare services delivery, management and planning (Kramer, 2012). In 1949, Gustav Wager of Germany founded the first professional organization for...
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...h o I s U s i n g H o w E m e r g e n c Emergency Department --- Waiting Time Analysisy A r e T h e y D e p a r t m e n t s W a i t i n g ? a n d L o n g All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system now known or to be invented, without the prior permission in writing from the owner of the copyright, except by a reviewer who wishes to quote brief passages in connection with a review written for inclusion in a magazine, newspaper or broadcast. Requests for permission should be addressed to: Canadian Institute for Health Information 495 Richmond Road, Suite 600 Ottawa, ON K2A 4H6 Phone: (613) 241-7860 Fax: (613) 241-8120 www.cihi.ca ISBN 1-55392-676-5 (PDF) © 2005 Canadian Institute for Health Information Cette publication est aussi disponible en français sous le titre : Comprendre les temps d’attente dans les services d’urgence : Qui utilise les services d’urgence et quels sont les temps d’attente?, 2005 ISBN 1-55392-678-1 (PDF) Table of Contents About the Canadian Institute for Health Information . . . . . . . . . . . . iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii About This Report . . . . . . . . . . . . . . . . ...
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...Foundations for an Electronic Medical Record “The reassessment of the basics of the medical record is timely for two causes. First, many of the technical limitations on storage and computing power which have in condition the design of existing electronic medical record systems are vanishing. Second, an amount of standards bodies are now watching at the medical record.”(A.L. Rector, W.A. Nolan & S. Kay). Most important pros of use electronic in medical records is the organized, arrangement and stay away from random, many workers got confused when search in patients’ files that have same name. The error in the files may leads to a number of problems including, the doctor...
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...EMR implementation to improve patient outcomes Florida International University The problem Quality of care has been low for Mesey hospital over the past few years. Medical errors, near misses and poor patient safety are at an increased rate. Communication has been lack luster, and patient satisfaction surveys have yielded unsatisfactory results. Mesey has invested in quality training, has had continuous education sessions and in-services in an attempt to improve care but has seen no improvements despite the efforts. The CEO, not realizing that it’s the system not the people, is looking into new and different strategies for improvement, including hiring new employees as the current staff is set in their ways and cannot seem to turn quality around. Mesey is currently using the traditional paper charting system and has not yet converted to electronic medical records (EMR). The CEO has done some research and has learned that the competitor Wellness hospital has been using EMR for over two years and has had great success - high quality rating and excellent patient satisfaction scores. The CEO of Mesey has been contemplating if implementing EMR within the facility will improve patient outcomes and satisfaction through improved safety and quality of care? Traditionally, paper based medical records have been used due to its simplicity and ease of use, low cost implementation, and widespread acceptance. This system does however come with a vast number of disadvantages including...
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...Discussion Health IT Adoption Introducing change in health care is never easy, i.e, the Obama Healthcare, (universal healthcare system) budget and implementation. By year 2014, the government will oversee that all Americans should receive healthcare regardless of pre-existing conditions, but that also means longer lines and longer services. Even with the change of technologies, I am sure there is significant doubt and opposition. So it comes as no surprise that in the face of changes of the adoption of health IT adoption – even though it carries the promise of improving the nation’s health care – some hospitals and providers will want to push back. Why should we care? The American people should care because they deserve better health care than they are currently receiving, and they need it delivered more efficiently. Health IT Adoption Plan is part of our economic recovery plan. Every provider, every patient throughout our nation will benefit from the goals envisioned by Health IT Adoption. Yes, this will be a challenge. While large hospital networks and smaller providers may be stretched to meet national health IT goals, it is not beyond their capacity for growth. There are incentive programs that will encourage and provide reimbursement to providers who have achieved meaningful use. This will also providing patients with improved quality and safety, more efficient care and save more lives and reduce redundant procedures which will save revenue...
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...Electronic health records (also known as ‘e-notes’, EMR or EHR) have commonly replaced the conventional paper records used in medical facilities. EHRs are a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports”. Some of the basic benefits associated with EHRs include being able to easily access computerized records and the elimination of poor penmanship, which has historically plagued the handwritten medical chart. This technology can offer a more consistent method for open communication among physicians, nurses, labs and other clinical staff without relying on handwritten notes stored in a single-location, electronic health records can help with the time it takes to treat someone. Electronic health records have provided a solution to a range of health care procedures, have offered cost savings and benefits, and still have greater potential for improvement through future efforts. It is evident that the EHRs have shortcomings that are commonly noted and targeted, but they have solved many more problems inherent in previous systems, they are the ideal path for development and improvement for patients and healthcare providers. Electronic health records have allowed healthcare organizations to provide quality care all of its...
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...Medical Smart Card System for Patient Record Management Changrui Xiao and Arthur Yu Bears Breaking Boundaries 2009 Science, Technology, and Energy Policy White Paper Competition Executive Summary (Abstract) Rising healthcare spending has led to an increase in calls for ways to reduce the cost of healthcare. Amid the debate on the best approach on cut costs in the healthcare system, one of the few bipartisan provisions is the need to integrate modern technology into the storage and transfer of medical records. Current attempts to establish such electronic medical records are challenged by concerns about patient privacy, issues with the incorporation of old records, and budget limitations. We propose the development of personal portable healthcare record smart cards and a corresponding framework to simplify maintenance and transfer of patient records as an incremental step towards a nationalized electronic records system. Our proposal is a feasible and cost-effective system that applies existing technology to address inefficiencies of the current paper based medical records system; simultaneously, it also serves as a transition system to facilitate the adoption of completely electronic medical records. Author Affiliations: Xiao and Yu are both undergraduates at UC Berkeley. Contact Information: ayu.yua@gmail.com or crx687@berkeley.edu 1 1. Introduction During the second half of the 20th century, the national expenditure on healthcare increased dramatically. As of...
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...00 DOI: 10.1037/a0016853 Electronic Medical Records: Confidentiality Issues in the Time of HIPAA Margaret M. Richards Cleveland Clinic Children’s Hospital With the application of the Health Insurance Portability and Accountability Act (HIPAA) in the medical community, new issues arise for psychologists in keeping documented records of patient visits. Confidentiality limits have broadened, making use of the electronic medical record more complicated for the psychologist practitioner, particularly when serving as part of a multidisciplinary team. As the electronic medical record (EMR) has become more prevalent in multiple settings, various researchers have examined the effectiveness of this record keeping system, with a focus on improving patient outcomes. The risks and benefits of implementing an EMR will be discussed, focusing on specific considerations for psychologists in regard to confidentiality and interdisciplinary collaboration. Keywords: Health Insurance Portability and Accountability Act (HIPAA), electronic medical record (EMR), confidentiality How much information is appropriate to place in an electronic medical record (EMR), especially when that record is accessible to professionals throughout an organization (i.e., a hospital setting)? This question has become an important topic of discussion and research as EMRs become more prevalent in larger institutions, such as academic medical centers and community mental health centers. With the implementation...
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...the users of the health record AND explain how each uses the record. (Complete for all that are listed in Abdelhak under the “health data users and uses” section. - Patient: uses their medical data to understand their health care and to become more active partners in maintain or improving their health. - Health care practitioners: uses it as a primary means of communications among themselves. - Health Care providers and Administrators: uses the data to evaluate care, monitor the use of resources, and receive payment for services rendered. Administrators analyze financial and patient case mix information for business planning and marketing activities - Third party payers: the data become the basis for determining the appropriate payment to be made. - Utilization and case managers: uses it to coordinate care so that the patient is cared for in the most clinically cost-effective manner. - Quality of care committees: use the information as a basis for analysis, study, and evaluation of the quality of care given to the patient. - Accrediting, licensing, and certifying agencies: use the record to provide public assurance that quality health care is being provided. - Governmental agencies and public health: to determine the appropriate use of the governmental financial resources for health care facilities and educational and correctional institutions - Health information exchanges: provides patient centered care that improves quality...
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...Benefits and Challenges of Computerized Physician Order Entry (CPOE): How are physicians affecting implementation? Anita Marban University of Maryland The Benefits and Challenges of Computerized Physician Order Entry (CPOE): How are physicians affecting implementation? Executive Summary: Physicians have always been the driving force behind the success of new technologies and their effects on healthcare. They are interested in new ways of providing care by utilizing medications or trying new procedures and medical devices. Through research they seek to understand the human body and find cures for the diseases that attack it. They spend years in school and incur debt in upwards of $200,000 dollars before they graduate and have the opportunity to practice independently. Confronted with technology that can improve patient safety by up to 95% and save billions of dollars, they resist change. In the U.S. less than 10% of hospitals and less that 25% of physician offices have fully functioning CPOE systems. Cedars Mt Sinai pulled the plug on their multi-million dollar CPOE system, as did 6 other hospitals because physicians refused to use them. A review of the literature shows that approximately 68% of physicians surveyed identify CPOE as the solution to preventing many medical errors, adopting best-clinical-practices and reducing healthcare costs by billions of dollars annually. It also shows that physicians have issues and concerns with adopting CPOE...
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...Office of the National Coordinator for Health Information Technology (ONC) Federal Health Information Technology Strategic Plan 2011 – 2015 Table of Contents Introduction Federal Health IT Vision and Mission Federal Health IT Principles Goal I: Achieve Adoption and Information Exchange through Meaningful Use of Health IT Goal II: Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT Goal III: Inspire Confidence and Trust in Health IT Goal IV: Empower Individuals with Health IT to Improve their Health and the Health Care System Appendix A: Performance Measures Appendix B: Programs, Initiatives, and Federal Engagement Appendix C: HIT Standards and HIT Policy Committees Information Flow Appendix E: Statutes and Regulations Appendix F: Goals, Objectives, and Strategies Appendix G: Acronyms ONC Acknowledgements Notes 3 6 7 8 21 28 36 49 51 65 67 70 74 77 77 78 Goal V: Achieve Rapid Learning and Technological Advancement 43 Federal Health IT Strategic Plan 3 Introduction he technologies collectively known as health information technology (health IT) share a common attribute: they enable the secure collection and exchange of vast amounts of health data about individuals. The collection and movement of this data will power the health care of the future. Health IT has the potential to empower individuals and increase transparency; enhance the ability to study care delivery and payment systems; and ultimately achieve...
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