Electronic Health Record
Standards, Coding Systems, Frameworks, and Infrastructures
Pradeep K. Sinha, Gaur Sunder, Prashant Bendale, Manisha Mantri, Atreya Dande
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Electronic Health Record
Standards, Coding Systems, Frameworks, and Infrastructures
Pradeep K. Sinha, Gaur Sunder, Prashant Bendale, Manisha Mantri, Atreya Dande
Ă propos de ce livre
Discover How Electronic Health Records Are Built to Drive the Next Generation of Healthcare Delivery
The increased role of IT in the healthcare sector has led to the coining of a new phrase "health informatics, " which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks. This book provides an overview of different health informatics resources and artifacts that underlie the design and development of interoperable healthcare systems and applications.
Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures compiles, for the first time, study and analysis results that EHR professionals previously had to gather from multiple sources. It benefits readers by giving them an understanding of what roles a particular healthcare standard, code, or framework plays in EHR design and overall IT-enabled healthcare services along with the issues involved.
This book on Electronic Health Record:
- Offers the most comprehensive coverage of available EHR Standards including ISO, European Union Standards, and national initiatives by Sweden, the Netherlands, Canada, Australia, and many others
- Provides assessment of existing standards
- Includes a glossary of frequently used terms in the area of EHR
- Contains numerous diagrams and illustrations to facilitate comprehension
- Discusses security and reliability of data
Foire aux questions
Informations
1.1 Introduction
1.2 Definition of EHR
- Electronic Medical Record(EMR). EMR is often used in parallel with EHR. It is a fully interoperable electronic health record of a patient within a healthcare organization. However, some people consider EMR as a set of records of a patient related to a single encounter or a single care episode. According to this view, EMR is a point-in-time view of a larger EHR. This approach considers an EHR to be sum total of all EMRs of a patient.
- Computer-Based Patient Record(CPR). CPR was first used to conceptualize the idea of EHR [Richard et al. 1997]. It is a lifetime health record of a patient, which includes information from all specialties. It requires full interoperability (potentially international interoperability) that may be achieved in the near future.
- Electronic Patient Record(EPR). EPR is similar to CPR, but does not necessarily contain a lifetime record and focuses on relevant information only.
- Personal Health Record(PHR). PHR is managed and controlled by a patient. It is mostly considered to be web-based. Usually, PHR is another patient-side view of an EHR/EMR maintained by a particular group of healthcare providers.
1.3 Functions of EHR
- Health Information and Data. It should store and provide access to health information of patients such as patient's history, allergies, laboratory reports, diagnosis, current medications, and so on, to healthcare providers for taking appropriate clinical decisions for better patient care. It should integrate data from various sources and make it available to the people involved in the care of a patient.
- Replicate the Workflow. It should be able to work in-sync with the original workflow of the healthcare organization.
- Efficient Interaction. It should be able to work effectively, saving time of care providers by keeping things concise.
- Clinical Decision Support (CDS). It should support provision of reminders, prompts, and alerts. Such features help in improving clinical and preventive practices and reduce frequency of adverse events.
- Patient Support. It should empower patients to access their health information, enabling them to be involved in their own healthcare.
- Messaging and Data Processing Capability. It should enable exchange of data in known/standard formats for interoperability of healthcare applications. Additionally, it should enable processing of incoming data in known/standard formats.
- Administrative Tools. It should provide administrative tools, such as scheduling systems, for improving efficiency of clinical practices and timely service to patients.
1.4 Significance of EHR
- Ease of Maintaining Health Information of Patients. An EHR system enables paperless medical treatment with less space required for storing health data of patients. Additionally, with proper backup policies, the lifespan of EHRs can be increased. This reduces the cost of generating, storing, and maintaining patient records in healthcare organizations.
- Efficient in Complex Environments. Large healthcare organizations have many specialty departments, laboratories, training and research centers, and so on. An EHR system helps in improving clinical processes or workflow efficiency across these units of a healthcare organization. For example, it enables an administrator to obtain data for billing, a physician to see progress of treatments, a nurse to report an adverse reaction, and a researcher to analyze efficacy of medications on patients.
- Better Patient Care. Often, multiple healthcare providers are involved in treatment of a patient. An EHR system allows sharing of the patient's information among them. Moreover, it enables point-in-time data insertion, retrieval, and update, thereby providing immediate access of patient data from any specialty center whenever required. This enables healthcare providers to make timely decisions for better patient care. Availability of health information, such as past medical history, family medical history, and immunization, through EHR helps in taking preventive measures and managing chronic diseases more effectively.
- Improve Quality of Care. EHR helps to decrease reporting and charting time during treatment, thereby improving quality of care. EHR also helps in improving risk management and accurate diagnosis, thereby improving quality of care.
- Reduce Healthcare Delivery Costs. Due to the availability of health information data from all healthcare organizations, a healthcare provider can refer to the required test reports, thus avoiding repetition of expensive tests.
- Accelerates Research and Helps Build Effective Medical Practices. EHR provides a large database at one place, enabling its use for disease surveillance for providing preventive measures. It also helps in analyzing treatment patterns of medicine, providing new ideas and ways of drug discovery. Decision support with EHR enables effective medical practices.
- Better Safety. Through access, audit, and authorization control mechanisms, an EHR system provides better safety to a patient's health records as compared to a paper-based system.
1.5 Factors Affecting Implementation of EHR
- Significant Changes in Clinical Workflow. Implementation of an EHR system in a healthcare organization often requires significant changes in the organization's clinical workflow. Hence, it is always good to make EHR a part of the strategic vision of the organization. Design of the system needs involvement of clinical staff with inclusion of organization's policies and workflow processes [Hamilton 2011].
- Privacy and Security. An EHR implementation must deal with privacy and security issues with great care because health care providers are concerned about alteration of EHR without their knowledge, and patients are concerned about unauthorized access to their private data.
- Unique Identification. Duplication of EHR records of a patient in the same EHR system is an important issue in EHR usage. This issue arises because healthcare data of a patient is often coll...