Capturing Social and Behavioral Domains in Electronic Health Records by Recommended Social and Behavioral Domains and Measures for Electronic Health Records Committee; Board on Population Health and Public Health Practice; Institute of MedicineSubstantial 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.
Publication Date: 2014-07-23
Ensuring the Integrity of Electronic Health Records : The Best Practices for e-Records Compliance by Orlando LópezData integrity is a critical aspect to the design, implementation, and usage of any system which stores, processes, or retrieves data. The overall intent of any data integrity technique is the same: ensure data is recorded exactly as intended and, upon later retrieval, ensure the data is the same as it was when originally recorded. Any alternation to the data is then traced to the person who made the modification. The integrity of data in a patient's electronic health record is critical to ensuring the safety of the patient. This book is relevant to production systems and quality control systems associated with the manufacture of pharmaceuticals and medical device products and updates the practical information to enable better understanding of the controls applicable to e-records. The book highlights the e-records suitability implementation and associated risk-assessed controls, and e-records handling. The book also provides updated regulatory standards from global regulatory organizations such as MHRA, Medicines and Healthcare Products Regulatory Agency (UK); FDA, Food and Drug Administration (US); National Medical Products Association (China); TGA, Therapeutic Goods Administration (Australia); SIMGP, Russia State Institute of Medicines and Good Practices; and the World Health Organization, to name a few.
Publication Date: 2020-12-22
The Lean Electronic Health Record by Kurt A. Knoth; Ronald G. Bercaw; Susan T. Snedaker, MBA, CISM, CPHIMS, CThe Electronic Health Record (EHR) is a reflection of the way your organization conducts business. If you're looking to make lasting improvements in the delivery of care, you must start with looking at the system from your patient's perspective to understand what is of value and what is simply waste. When you begin seeing in this way, you'll begin building in this way. When you begin building in this way, you'll begin driving improvements in your care delivery. Only then will your EHR be able to support lasting improvements, driving better patient care and outcomes at lower costs. Healthcare organizations are under increasing pressure to improve on all fronts. This can be achieved, but only by changing the very way we look at care. No longer can we look at care just from the organization or provider's perspective; we must start with the end in mind - the patient. Compelling case studies, discussed throughout this book, demonstrate that modifying processes and workflows using Lean methodologies lead to substantial improvements. These changes must be undertaken in a clear, consistent, and methodical manner. When implementing an EHR based on existing workflows and sometimes antiquated processes, organizations struggle to sustain improvements. Many organizations have deployed an EHR and now face optimization challenges, including the decision to move to a new EHR vendor. The financial implications of upgrading, optimizing or replacing an EHR system are significant and laden with risk. Choose the wrong vendor, the wrong system, or the wrong approach and you may struggle under the weight of that decision for decades. Organizations that successfully leverage the convergence of needs - patients demanding better care, providers needing more efficient workflows and organizations desiring better financials - will survive and thrive. This book ties together current healthcare challenges with proven Lean methodologies to provide a clear, concise roadmap to help organizations drive real improvements in the selection, implementation, and on-going management of their EHR systems. Improving patient care, improving the provider experience and reducing organizational costs are the next frontier in the use of EHRs and this book provides a roadmap to that desired future state.
Publication Date: 2018-01-11
New Perspectives in Medical Records by Giovanni Rinaldi (Editor)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.
Publication Date: 2017-03-29
Health Insurance Portability and Accountability Act (HIPAA)