Medical Informatics Computer Applications in Health Care and Biomedicine
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Individuals' Use of Online Medical Records and Technology for Health
ONC Data Brief ■ No. 40 ■ April 2018 Individuals’ use of online medical records and technology for health needs Vaishali Patel, MPH PhD & Christian Johnson, MPH 1 Individuals’ electronic access and use of their health information will be critical towards enabling individuals to better monitor their health as well as manage and coordinate their care. Past efforts sought to provide individuals the capabilities to view, download, and transmit their patient health information. Building on these efforts, the 21st Century Cures Act (Cures Act) includes provisions to improve patients’ access and use of their electronic health information via a single, longitudinal format that is secure and easy to understand.1 The Cures Act also calls for patients to be able to electronically share their information. Online access to medical records, such as through patient portals, enable patients and caregivers to access their health information. Mobile health apps and devices connected to a providers’ electronic health record system using open application programming interfaces (APIs) will also allow individuals to collect, manage, and share their health information. Using the National Cancer Institute’s 2017 Health Information Trends Survey, we report on access and use of online medical records and the use of technology such as smartphones, tablets, and electronic monitoring devices (e.g. Fitbits, blood pressure monitors) for health related needs.2 HIGHLIGHTS As of 2017, 52 percent of individuals have been offered online access to their medical record by a health provider or insurer. Over half of those who were offered online access viewed their record within the past year; this represents 28 percent of individuals nationwide. -
Medical Record Review Guidelines California Department of Health Services Medi-Cal Managed Care Division
Medical Record Review Guidelines California Department of Health Services Medi-Cal Managed Care Division Purpose: Medical Record Survey Guidelines provide standards, directions, instructions, rules, regulations, perimeters, or indicators for the medical record survey, and shall used as a gauge or touchstone for measuring, evaluating, assessing, and making decisions.. Scoring: Survey score is based on a review standard of 10 records per individual provider. Documented evidence found in the hard copy (paper) medical records and/or electronic medical records are used for survey criteria determinations. Full Pass is 100%. Conditional Pass is 80-99%. Not Pass is below 80%. The minimum passing score is 80%. A corrective action plan is required for all medical record criteria deficiencies. Not applicable (“N/A”) applies to any criterion that does not apply to the medical record being reviewed, and must be explained in the comment section. Medical records shall be randomly selected using methodology decided upon by the reviewer. Ten (10) medical records are surveyed for each provider, five (5) adult and/or obstetric records and five (5) pediatric records. For sites with only adult, only obstetric, or only pediatric patient populations, all ten records surveyed will be in only one preventive care service area. Sites where documentation of patient care by all PCPs on site occurs in universally shared medical records shall be reviewed as a “shared” medical record system. Scores calculated on shared medical records apply to each PCP sharing the records. A minimum of ten shared records shall be reviewed for 2-3 PCPs, twenty records for 4-6 PCPs, and thirty records for 7 or more PCPs. -
World Journal of Advanced Research and Reviews
World Journal of Advanced Research and Reviews, 2020, 07(02), 218–226 World Journal of Advanced Research and Reviews e-ISSN: 2581-9615, Cross Ref DOI: 10.30574/wjarr Journal homepage: https://www.wjarr.com (RESEARCH ARTICLE) Implementation and evaluation of telepharmacy during COVID-19 pandemic in an academic medical city in the Kingdom of Saudi Arabia: paving the way for telepharmacy Abdulsalam Ali Asseri *, Mohab Mohamed Manna, Iqbal Mohamed Yasin, Mashael Mohamed Moustafa, Fatmah Mousa Roubie, Salma Moustafa El-Anssasy, Samer Khalaf Baqawie and Mohamed Ahmed Alsaeed Associate Professor Imam Abdulrahman Bin Faisal University; Director of Pharmacy services at King Fahad University Hospital, KSA. Publication history: Received on 07 July 2020; revised on 22 August 2020; accepted on 25 August 2020 Article DOI: https://doi.org/10.30574/wjarr.2020.7.2.0250 Abstract King Fahad University Hospital, a leading public healthcare institution in the Eastern region of KSA, implemented a disruptive innovation of Telepharmacy in pursuit of compliance with the National COVID-19 Response Framework. It emerged and proved to be an essential and critical pillar in suppression and mitigation strategies. Telepharmacy innovation resulted in Pharmacy staffing protection and provided uninterrupted access and care continuum to the pharmaceutical services, both for COVID-19 and Collateral care. This reform-oriented initiative culminated in adopting engineering and administrative controls to design the workflows, practices, and interactions between healthcare providers, patients, and pharmaceutical frontline staff. Pharmaceutical services enhanced its surge capacity (14,618 OPD requests & 10,030 Inpatient orders) and improved capability (41,242 counseling sessions) to address the daunting challenge of complying with the inpatient needs and robust outpatient pharmaceutical consumer services. -
Computing the Future
STA2015 1/8/2015 Computing the Future The Evolving Roles of Informatics and Information Technology in Health Care Edward H. Shortliffe, MD, PhD Professor of Biomedical Informatics and Senior Advisor to the Executive Vice Provost College of Health Solutions, Arizona State University Adjunct Faculties, Columbia University and Weill Cornell Medical College Annual Meeting Society for Technology in Anesthesia Royal Palms Resort & Spa Phoenix, AZ January 8, 2014 ©EHShortliffe 2015 1 STA2015 1/8/2015 ©EHShortliffe 2015 2 STA2015 1/8/2015 What I Would Like to Discuss . •Reflections on the evolution of technologies in our society, to provide context for considering health information technology (HIT) and its future •Discussion of the evolution of informatics as a discipline •Some words about nomenclature •Relationship of informatics to HIT • Assessment of our current state •Some examples from anesthesiology •Anticipating future directions ©EHShortliffe 2015 3 STA2015 1/8/2015 Analogy: Commercial Aviation Roughly where we are today in the evolution of health information technology relative to what we envision Analogy: Evolution of Personal Computing Devices ©EHShortliffe 2015 4 STA2015 1/8/2015 1980s Subsequently .. •Network connectivity (Internet and wireless) •Modern PCs, Macs, netbooks, etc. •Smartphones •Tablet computing •Smart devices •Personal devices •And more to come . ©EHShortliffe 2015 5 STA2015 1/8/2015 The Evolving Paradigm White House at night President Bush calls for universal implementation of electronic health records within 10 years -
A Study of the Management of Electronic Medical Records in Fijian Hospitals
A Study of the Management of Electronic Medical Records in Fijian Hospitals Swaran S. Ravindra1*& Rohitash Chandra2*& Virallikattur S. Dhenesh1* 1 School of Computing, Information and Mathematical Sciences, University of the South Pacific, Laucala Campus, Fiji 2 Artificial Intelligence and Cybernetics Research Group, Software Foundation, Nausori, Fiji *Authors are in order of contribution. Email addresses: SSR: [email protected] RC: [email protected] VSD: [email protected] Page 1 of 24 Key Words: Australian Agency for International Development (AusAID) – is an Australian agency that manages development and assistance projects internationally. AusAID has recently been absorbed into the Australian Department of Foreign Affairs and Trade [1] . Biomedical Informatics – is the field of science that develops theories, techniques, methods pertaining to the use data, information and knowledge which support and improve biomedical research, human health, and the delivery of healthcare services [2] . Cloud Computing- refers to Information Technology services leased to a person or organization over internet network according to service level requirements. It requires minimal management effort or service provider interaction [3] e-Health- an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered through the Internet and related technologies [4]. Electronic Medical Record (EMR)- An electronic medical record (EMR) is a digital version of a patient’s medical -
The Electronic Medical Record: Promises and Problems
The Electronic Medical Record: Promises and Problems William R. Hersh Biomedical Information Communication Center, Oregon Health Sciences University, BICC, 3 18 1 S. W. Sam Jackson Park Rd., Portland, OR 97201. Phone: 503-494-4563; Fax: 503-494-4551; E-mail: [email protected] Despite the growth of computer technology in medicine, the form of progress notes, which are written for each most medical encounters are still documented on paper encounter with the patient, whether done daily in the medical records. The electronic medical record has nu- hospital setting or intermittently as an outpatient. Inter- merous documented benefits, yet its use is still sparse. This article describes the state of electronic medical re- spersed among the records of one clinician are those of cords, their advantage over existing paper records, the other clinicians. such as consultants and covering col- problems impeding their implementation, and concerns leagues, as well as test results (i.e., laboratory or x-ray over their security and confidentiality. reports) and administrative data. These various components of the records are often As noted in the introduction to this issue, the provi- maintained in different locations. For example, each sion of medical care is an information-intensive activity. physician’s private office is likely to contain its own re- Yet in an era when most commercial transactions are cords of notes and test results ordered from that office. automated for reasons of efficiency and accuracy, it is Likewise, all of a patient’s hospital records are likely to somewhat ironic that most recording of medical events be kept in a chart at the hospital(s) where care is ren- is still done on paper. -
A Career in Health Care Informatics: the Outlook and Options Table of Contents a Career in Health Care Informatics: the Outlook and Options
A Career in Health Care Informatics: The Outlook and Options Table of Contents A Career in Health Care Informatics: The Outlook and Options Introduction 3 Health Care Informatics vs. Nursing Informatics 5 Job Growth and Outlook 6 Careers in Health Care Informatics 12 Chief Medical Information Officer (CMIO) 14 Director of Clinical Information Systems 16 Data Scientist 18 Health Informatics Consultant 19 Professor of Health Informatics 21 Researcher 22 Breaking into the Field 24 INTRODUCTION Health Care Informatics Vs. Nursing Informatics Health care informatics has been a distinct discipline for several decades now. But it has moved to the forefront over the last five years with health care organizations making the transition to electronic health records (EHRs). Today, the health care informatics industry is exploding and the Bureau of Labor Statistics predicts that jobs in the field will “grow much faster than the average for all occupations.” Defined by the U.S. National Library of Medicine as the “interdisciplinary study of the design, development, adoption and application of IT-based innovations in health care services delivery, management and planning,” health care informatics was propelled to popularity with the passage of the Health Information Technology for Economic and Clinical Health Act. Under this law, health centers, including hospitals, clinics and private physician offices, were required to create and maintain electronic medical records for every patient by the year 2015. 3 INTRODUCTION Health Care Informatics Vs. Nursing Informatics By now, the majority of health centers have moved to electronic patient records, which has created enormous possibilities in the field of health informatics. -
Health Information Technology
Published for 2020-21 school year. Health Information Technology Primary Career Cluster: Business Management and Technology Course Contact: [email protected] Course Code: C12H34 Introduction to Business & Marketing (C12H26) or Health Science Prerequisite(s): Education (C14H14) Credit: 1 Grade Level: 11-12 Focused Elective This course satisfies one of three credits required for an elective Graduation Requirements: focus when taken in conjunction with other Health Science courses. This course satisfies one out of two required courses to meet the POS Concentrator: Perkins V concentrator definition, when taken in sequence in an approved program of study. Programs of Study and This is the second course in the Health Sciences Administration Sequence: program of study. Aligned Student HOSA: http://www.tennesseehosa.org Organization(s): Teachers are encouraged to use embedded WBL activities such as informational interviewing, job shadowing, and career mentoring. Coordinating Work-Based For information, visit Learning: https://www.tn.gov/content/tn/education/career-and-technical- education/work-based-learning.html Available Student Industry None Certifications: 030, 031, 032, 034, 037, 039, 041, 052, 054, 055, 056, 057, 152, 153, Teacher Endorsement(s): 158, 201, 202, 203, 204, 311, 430, 432, 433, 434, 435, 436, 471, 472, 474, 475, 476, 577, 720, 721, 722, 952, 953, 958 Required Teacher None Certifications/Training: https://www.tn.gov/content/dam/tn/education/ccte/cte/cte_resource Teacher Resources: _health_science.pdf Course Description Health Information Technology is a third-level applied course in the Health Informatics program of study intended to prepare students with an understanding of the changing world of health care information. -
Health Care Informatics Keng Siau
IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 7, NO. 1, MARCH 2003 1 Health Care Informatics Keng Siau Abstract—The health care industry is currently experiencing a fundamental change. Health care organizations are reorganizing their processes to reduce costs, be more competitive, and provide better and more personalized customer care. This new business strategy requires health care organizations to implement new tech- nologies, such as Internet applications, enterprise systems, and mo- bile technologies in order to achieve their desired business changes. This article offers a conceptual model for implementing new in- formation systems, integrating internal data, and linking suppliers and patients. Index Terms—Bioinformatics, data mining, enterprise systems, health informatics, information warehouse, internet, mobile tech- nology, patient relationship management, telemedicine. I. INTRODUCTION Fig. 1. Health care supply chain. NFORMATION technology has expanded to encompass I nearly every industry in the world from finance and banking to universities and nonprofit organizations. The health placement for the physician–patient relationship; instead it is care industry, which is composed of hospitals, individual meant to enhance this relationship, by making both physicians physician practices, specialty practices, as well as managed and patients better informed. care providers, pharmaceutical companies, and insurance companies, is no exception. The industry’s expanded interest II. CURRENT USE OF IT IN HEALTHCARE in information systems implementation has primarily been Current literature on the deployment of information systems fueled by needs for cost efficiency, increased competition, as in the health care sector shows that most organizations are al- well as a fundamental change in the health care industry, in locating a relatively small amount of resources toward informa- which providers have changed their focus from reactive care tion systems. -
Telehealth Transformation: COVID-19 and the Rise of Virtual Care
Journal of the American Medical Informatics Association, 0(0), 2020, 1–6 doi: 10.1093/jamia/ocaa067 Perspective Perspective Downloaded from https://academic.oup.com/jamia/advance-article-abstract/doi/10.1093/jamia/ocaa067/5822868 by guest on 01 June 2020 Telehealth transformation: COVID-19 and the rise of virtual care Jedrek Wosik,1 Marat Fudim,1 Blake Cameron,2 Ziad F. Gellad,3,4 Alex Cho,5 Donna Phinney,6 Simon Curtis,7 Matthew Roman,6,8 Eric G. Poon ,5,6 Jeffrey Ferranti,6,8,9 Jason N. Katz,1 and James Tcheng1 1Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA, 2Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA, 3Division of Gastroen- terology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA, 4Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, North Carolina, USA, 5Division of General Internal Medicine, De- partment of Medicine, Duke University School of Medicine, Durham, North Carolina, USA, 6Duke Network Services, Duke Univer- sity Health System, Durham, North Carolina, USA, 7Private Diagnostic Clinic, Duke Health Access Center, Durham, North Carolina, USA, 8Duke Health Technology Solutions, Durham, North Carolina, USA and 9Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA Corresponding Author: Jedrek Wosik, MD, Division of Cardiology, Department of Medicine and Division of Cardiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, USA; [email protected] Received 14 April 2020; Editorial Decision 15 April 2020; Accepted 17 April 2020 ABSTRACT The novel coronavirus disease-19 (COVID-19) pandemic has altered our economy, society, and healthcare system. -
Module 7 – Hospital and Health Record Computer Applications
Module 7 – Hospital and Health Record Computer Applications The purpose of this module is to provide the user with basic and fundamental knowledge of health care information systems in the healthcare environment with emphasis on applications that relate to the use and storage of patient’s health and clinical information. See additional modules including Module 2 which specifically addresses the Patient Master Index application in further detail. In this unit we will: • Discuss information systems and applications in general in the health care facility • Identify the operations within the medical record service that can be computerised • Identify priorities for implementation using a planned information system strategy OBJECTIVES: Upon completion of this unit participants should be able to: 1. Identify general health care applications found in health care facilities 2. identify applications within a medical record department which could be considered for computerisation 3. Discuss the important points relating to a computerised Master Patient Index 4. State the objectives of a computerised admission, discharge and transfer system (ADT) 5. List the daily reports generated by a computerised ADT system 6. Discuss the basic functionality of a data base system as it relates to use in a healthcare facility 7. Discuss advantages and disadvantages of information systems in health facilities in general Key Definitions: • ADT/ATD – a program used in a healthcare facility that contains information about a patient with regard to facility admission (date and location/bed/ward), transfer information if the patient was moved to another location and the date of discharge which may include whether the patient was transferred to another facility, discharged to home or if the patient expired (died). -
How to Conduct a Medical Record Review
How to Conduct a Medical Record Review WHITE PAPER Summary: This paper defines a recommended process for medical record review. This includes the important first step of defining the “why” behind the review, and marrying the review outcome to organizational goals. Medical record review is perhaps the core responsibility of the CDI profession- z FEATURES al. Although the numbers vary by facility, CDI specialists review an average of 16–24 patient charts daily, a task that compromises the bulk of their workday Aligning record reviews to (ACDIS, 2016).1 During the review, CDI professionals comb the chart for incom- organizational goals .................2 plete, imprecise, illegible, conflicting, or absent documentation of diagnoses, Principles of record procedures, and treatments, as well as supporting clinical indicators. Their review .......................................3 goal is to cultivate a medical record that stands alone as an accurate story of a ED/EMS notes ..........................5 patient encounter, providing a full picture of the patient’s illness and record of History and physical (H&P) ......6 treatment. A complete record allows for continuity of care, reliable collection of Operative note or bedside mortality and morbidity data, quality statistics, and accurate reimbursement. procedures ...............................7 Diagnostics and medications ...8 In their review of the medical record, CDI professionals aim to reconstruct the Progress notes, consults, and patient story from admission to discharge by examining, understanding, and nursing documentation ............9 synthesizing many puzzle pieces from disparate systems and people. This Initial vs. subsequent process requires considerable clinical acumen, critical thinking akin to detective reviews .....................................9 work, and knowledge of coding guidelines and quality measure requirements.