Electronic Health Records

552 Pages·2008·153.44 MB·English

by  Jerome H. Carter

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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
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