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Electronic Health Records PDF

552 Pages·2008·153.44 MB·English
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I z ft 0 ACP cr - V n BIH Electronic Health Records Second Edition A Guide for Clinicians and Administrators Jerome H. Carter, MD Electronic Health Records Second Edition ELECTRONIC HEALTH RECORDS A Guide for Clinicians and Administrators Second Edition Jerome H. Carter, MD, FACP ACP PRESS American College of Physicians Philadelphia Associate Publisher and Manager, Books Publishing: Tom Hartman Production Supervisor: Allan S. Kleinberg Senior Editor: Karen C. Nolan Editorial Coordinator: Angela Gabella Cover Design: Lisa Torrieri Index: Kathleen Patterson Copyright © 2008 by the American College of Physicians. All rights reserved. No part of this book may be reproduced in any form by any means (electronic, me- chanical, xerographic, or other) or held in any information storage and retrieval systems without written permission from the publisher. Printed in the United States of America Printing/binding by Versa Press Composition by Atlis Graphics Publisher's Note: Although a number of EHR vendors and products are men- tioned within the text of this book, and some chapter authors are formally affiliated with an EHR vendor, this in no way implies an endorsement of the products or vendors by the editor or the American College of Physicians. Library of Congress Cataloging-in-Publication Data Electronic health records : a guide for clinicians and administrators / editor, Jerome H. Carter.—2nd ed. p. ; cm. Rev. ed. of: Electronic medical records. c2001. Includes bibliographical references and index. ISBN 978-1-930513-97-6 1. Medical records—Data processing. 1. Carter, Jerome, 1955- IE Electronic medical records. [DNLM: 1. Medical Records Systems, Computerized. 2. Forms and Records Control—methods. WX 173 E373 2008] R864.A42 2008 610.285—dc22 2007049164 08 09 10 11 12 / 10 9 8 7 6 5 4 3 2 1 Dedication This is to all those people who have made my life possible: LaSalle and Viola Carter, my parents for inspiring me Janice, my wife, for her love and support Janie Herbert, the best mother-in-law ever And my daughter Joy, whose name says it all. V Contributors Jeroan J. Allison, MD, MS Daniel C. Davis, Jr., MD, FACP Professor of Medicine, Divisions of CEO, Interactive Care Technologies General Internal Medicine and Honolulu Preventive Medicine Assistant Chief Department of Assistant Dean for Continuing Medicine Medical Education Queen's Medical Center University of Alabama at Honolulu Birmingham Clinical Associate Professor of Birmingham, AL Medicine John A Burns School of Medicine Lyle Berkowitz, MD University of Hawaii Clinical Associate Professor of Honolulu, HI Medicine Feinberg School of Medicine Erica L. Drazen, ScD, BS Northwestern University Vice President Medical Director of Clinical First Consulting Group Information Systems Lexington, MA Northwestern Memorial Physicians Group (NMPG) Thomas K. Houston, MD, MPH Chicago, IL Associate Professor of Medicine LJniversity of Alabama at Stephen E. Brossette, MD, PhD Birmingham Vice President Birmingham, AL Cardinal Health Birmingham, AL JohnJ. Janas III, MD CEO, Clinical Content Jerome H. Carter, MD, FACP Consultants CEO Concord, NH NT&M Informatics, Inc. Adjunct Clinical Associate Professor Merida L. Johns, PhD of Medical Education President, Holistic Solutions Morehouse School of Medicine Visiting Professor Atlanta, GA College of St. Scholastica Woodstock, IL Sarah T. Corley, MD, FACP Chief Medical Officer Terri Thompson Mallett, Esquire NextGen Healthcare Information Administrative Law Judge Systems, Inc. District of Columbia Government Horsham, PA Washington, DC viii ELECTRONIC HEALTH RECORDS Naveen Maram, MD, MSHI, MPH Ashwin B. Philar, MSEE Medical Vocabulary Engineer McKesson Senior Software Engineer Intermountain Healthcare San Francisco, CA Salt Lake City, UT Caroline Samuels, MD Daniel R. Masys, MD Core Teaching Faculty Professor and Chair Howard University Medical Center Dept. of Biomedical Informatics Washington, DC Vanderbilt University School of Teaching Faculty, Internal Medicine Prince George's Hospital Center Medicine Bethesda, MD Nashville, TN Bruce Slater, MD, MPH Blackford Middleton, MD, MPH, Associate Professor (CHS) of MSc, FACP Medicine and of Biostatistics and Assistant Professor of Medicine Medical Informatics Harvard Medical School School of Medicine and Public Health Associate Physician University of Wisconsin Brigham & Women's Hospital Medical Director of Computerized Boston, MA Decision Support Partners HealthCare System University of Wisconsin Hospital Wellesley, MA and Clinics Madison, WI Suchit Mishra, MSEE Security Researcher Thomas C. Tinstman, MD Adobe Systems Inc. Independent Consultant and San Jose, CA Senior Advisor Health Technology Center Matthew Morgan, MD, MSc, San Francisco, CA FRCP(C) Courtyard Group Ltd; Feliciano B. Yu, Jr., MD, MSHI, Faculty of Medicine University of MSPH, CPHIMS Toronto Assistant Professor, Department University Health Network of Pediatrics Toronto, Ontario, Canada University of Alabama School of Medicine at Birmingham Jerome A. Osheroff, MD, FACP, Medical Informaticist FACMI Children's Health System Chief Clinical Informatics Officer Information Technology Thomson Healthcare Division Adjunct Assistant Professor of Birmingham, AL Medicine University of Pennsylvania Health System Cherry Hill, NJ Preface to the Second Edition Much has changed in the world of electronic health records (EHRs) since the first edition. What is perhaps the most important event occurred in the summer of 2003 when the Department of Health and Human Services asked the Institute of Medicine to provide specific guidance in helping to understand what capabilities an EHR should have in order to support patient care. The outcome of that request was the document "Key Capabilities of an Electronic Health Record System". This document was then used by HL-7 to create a functional model for EHRs that then became the basis for the criteria used for certifying EHR products by the Certification Commission for Health Information Technol- ogy (CCHIT). EHRs are increasingly seen as the key technology in address- ing concerns in patient safety, quality of care, and cost reduction. This viewpoint is reflected by the 2005 creation of the federal-level Office of the National Coordinator for Health Information Technology (ONCHIT), which is charged with overseeing the widespread adoption of health infor- mation technology. Many states, with California and Massachusetts being excellent examples, are actively pursuing EHR adoption. Thus, EHRs, which were little more than a curiosity when this book was conceived in 1999, have become mainstream products and a major part of health care delivery. On a more personal note, when the first edition of this book was published in 2001, I was Director of Informatics at the 1917 Patient Care and Research Clinic, University of Alabama-Birmingham. In that role I led a four-year effort to design and implement an EHR. That effort was com- pleted successfully in September 2004, and the 1917 Computer-Based Patient Record is now in active use supporting HIV/AIDS clinical activities. (Those who wish to know more about the 1917 CPR may download a ix

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