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Practical EHR: Electronic Record Solutions for Compliance and Quality Care [Pehme köide]

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  • Formaat: Paperback / softback, 422 pages, Figures; Tables, black and white; Illustrations, black and white
  • Ilmumisaeg: 01-Jun-2008
  • Kirjastus: American Medical Association
  • ISBN-10: 1579479871
  • ISBN-13: 9781579479879
Teised raamatud teemal:
Practical EHR: Electronic Record Solutions for Compliance and Quality CareSuurem pilt
  • Formaat: Paperback / softback, 422 pages, Figures; Tables, black and white; Illustrations, black and white
  • Ilmumisaeg: 01-Jun-2008
  • Kirjastus: American Medical Association
  • ISBN-10: 1579479871
  • ISBN-13: 9781579479879
Teised raamatud teemal:
Püsilink: https://www.kriso.ee/db/9781579479879.html
Märksõnad:
"The book focuses on the medical history and physical examination (H&P) feature of EHR and effective physician training for it's use"--Provided by publisher.

For physicians and their staff, this resource describes how to use electronic health records systems, focusing on the history and physical examination component. The importance of this component is detailed, as are individual practice medical and compliance requirements. Levinson outlines standards for design features as well as a protocol that provides medical practices with control over the selection, design customization, physician training, improvement process, and transformation from paper to electronic records. Design issues and solutions for different parts of the component are detailed. Levinson had a private practice for 26 years and has since devoted his energy to physician concerns, patient care issues, challenges in the health care system, and evaluation and management coding and documentation. Annotation ©2008 Book News, Inc., Portland, OR (booknews.com)
Preface ix
Acknowledgments xv
About the Author xvii
Introduction xix
PART 1: SURVEYING PHYSICIANS'H&P: CHALLENGES, TOOLS, AND STANDARDS
What Physicians Want: The EHR at the Point of Care
3(12)
Five Medical Practice Priorities
3(3)
Importance of Additional EHR Features
6(1)
Analysis of the Five Practice Priorities
7(1)
The Health Information Technology Lexicon
8(5)
Summary
13(2)
Surveying the Electronic Chasm, Its Depth and Its Causes
15(14)
Unreliable Implementation Results
15(2)
Reduced Efficiency of Entry of Individualized Narrative Data
17(1)
Reduced Productivity Following Implementation of an EHR system
17(1)
Noncompliant E/M Documentation and Coding
18(2)
Charts with Restricted Documentation Features Can Compromise Quality of Care
20(2)
Excessive Training Time for the Electronic H&P Component
22(1)
Underlying Causes of the Electronic Chasm
23(1)
Practical EHR Goals, Requirements, and Standards For Success
24(2)
Summary
26(3)
Quality Care, the Medical Diagnostic Process, the Physicians' Medical Record, and E/M Compliance
29(20)
Quality Care
29(2)
The Medical Diagnostic Process and Quality Care
31(2)
Structured Medical Records and The Promotion of Quality Patient Care
33(4)
E/M Compliance, the Medical Record, and the Diagnostic Process
37(3)
Obstacles to Overcome
40(5)
Summary
45(4)
Information Integration: Data, Protocols, and Process
49(20)
Data
50(2)
Protocols
52(4)
Process
56(6)
E/M Compliance, the Diagnostic Process, and Medical Record Solutions
62(1)
Summary
63(6)
PART 2: ANALYZING PREVALENT ELECTRONIC H&P DESIGN CHARACTERISTICS
Assessing Potential Barriers to Success With Electronic H&P
69(16)
Surveying the Current Electronic H&P Landscape
70(8)
Overview of Electronic H&P Challenges
78(3)
Placing H&P Design Issues on the EHR Enhancement Agenda
81(1)
Summary
81(4)
Toolkit for Analyzing Electronic H&P Software
85(8)
Evolution of the Current E/M Compliance Paradox
85(2)
Medical Record Design Elements
87(4)
Summary
91(2)
The Source of Electronic H&P Design Issues
93(28)
Reimbursement Policies and Patient Care
93(2)
Identifying the Common Causes of Data Entry Design Problems
95(1)
The Evolution of H&P Design and Functionality
96(2)
Copy and Paste Functionality
98(1)
Graphic User Interface Issues
99(4)
Narrative Interface Issues
103(7)
Summary of Problems With the Use of Macros
110(4)
Increasing Speed Is Not The Same Achieving Efficiency
114(1)
E/M Compliance and the Need to Address Medical Necessity
115(3)
Summary
118(3)
Data Entry Design Issues: The Medical History Component
121(16)
Potential Side Effects of Increasing Speed of Documentation
121(1)
Overview of the Medical History Component
122(1)
Chief Complaint and PFSH (Initial Visit)
123(2)
Review of Systems (Initial Visit)
125(3)
PFSH and ROS (Established Patient Visit)
128(6)
Summary
134(3)
Data Entry Design Issues: Examination, Making Decision Making, and Nature of the Presenting Problem
137(16)
Analyzing the Physical Examination Component
138(3)
Analyzing MDM
141(5)
Analyzing the NPP
146(1)
Coding Software Compliance Limitations
147(2)
Summary
149(4)
PART 3: REENVISIONING THE ELECTRONIC H&P
Design and Functionality Criteria for H&P Success
153(16)
Overview of Part 3
154(1)
Goals for the Electronic H&P
154(2)
Goals for Design
156(8)
Goals for Functionality
164(2)
H&P ``Look and Feel''
166(1)
Summary
167(2)
Data Entry Parameters and the H&P Design Toolkit
169(24)
Options for Data Entry Personnel
169(2)
Options for Delayed Data Entry
171(1)
Physician Transformation
172(1)
Assembling the Data Entry Toolkit
172(5)
Toolkit for Data Entry by Writing and Dictation
177(7)
Functionality and Protocol
184(5)
Summary
189(4)
Design Solutions for the Medical History Component
193(22)
Chief Complaint, PFSH, and ROS: Initial Visit
193(15)
PFSH and ROS: Follow-up Visits
208
History of Present Illness (HPI)
206(5)
Data Entry Tools Available for the Medical History
211(1)
Functionality of the Medical History Component of EHRs
212(1)
Summary
213(2)
Design Solutions for the Nature of the Presenting Problem
215(10)
Integrating the NPP into Software Design
215(1)
Design for Compliance, Quality, and Efficiency
216(5)
Design and Functionality for Physicians Working Wiht a Paper Data Transfer Medium
221(1)
Design and Functionality for Physicians Performing Direct Data Entry
221(1)
Summary
222(3)
Design Solutions for the Physical Examination Record
225(16)
Design for Compliance, Quality, and Efficiency
226(5)
Design Enhancements for the Graphic Interface Section
231(3)
Data Entry Tools Available for the Physical Examination Record
234(4)
Functionality of the Physical Examination Record
238(1)
Summary
239(2)
Design Solutions for Medical Decision Making and Final Nature of the Presenting Problem
241(22)
Identifying Current MDM Challenges
241(3)
EHR Design and Functionality Principles to Address the MDM Challenges
244(7)
Design Features for Each Section of MDM Documentation
251(1)
EHR Design Considerations for Impressions, Plans, and Data Ordered
252(2)
Data Entry Tools Available for MDM
254(1)
Functionality of MDM Documentation and the NPP
255(6)
Summary
261(2)
Additional Design Features for the Electronic H&P
263(22)
Time-Based E/M Care (Counseling Visits)
264(2)
Unconventional E/M Services
266(1)
Documentation Tools To Help Physicians Working With Other Clinicians
266(1)
Patient Educational Materials
267(1)
``Translational'' Consultation Reports
267(1)
Subsequent Care: Summary Screen for Prior Encounter
268(3)
Patient Profile Section
271(2)
Report Design and Protocol Functionality
273(4)
Charge Entry Options
277(4)
Summary
281(4)
PART 4: PRACTICE TRANSFORMATION AND HEALTH INFORMATION TRANSFORMATION
Roadmap for Successful Practice Transformation: Avoiding the Electronic Chasm
285(10)
The Medical Practice Transformation Process
286(3)
The Practice Transformation Pyramid
289(2)
Timing
291(3)
Summary
294(1)
Preparation for Practice Transformation
295(14)
Building a Transformation Team
295(2)
Establishing Criteria for the Electronic H&P
297(5)
Establishing Benchmarks
302(1)
Setting Economic Parameters
302(5)
Summary
307(2)
Practice Transformation: Foundation Level
309(14)
Initial Investigations
310(1)
Overview of Software Evaluation
311(3)
Software Evaluation Tools
314(2)
Developing an Iterative Process
316(3)
Investing in a Solid Foundation
319(2)
Summary
321(2)
Practice Transformation: Health Information Transformation (HITr)
323(18)
Workflow Transformation
323(3)
Components of Health Information Transformation (HITr)
326(1)
Physician Compliance Assessment and Training
326(7)
Confirmation of EHR Design and Functionality Customizations
333(1)
Verification of Successful Transformation
334(3)
Streamlining the HITr Process Following Initial Success
337(1)
Value of the HITr Process
338(1)
Summary
338(3)
Assessment and Transformation for Practices Already Using EHRs
341(10)
Status of Groups Currently Using EHRs
342(1)
The EHR Assessment Process for a Practice
342(5)
Temporizing Measures
347(1)
Summary
348(3)
Conclusion: The Role of Practical EHR in Health Information Technology
351(2)
Appendix A: Calculating Costs of Paper-Based Medical Records 353(4)
Appendix B: Calculating Medical Practice Overhead Costs 357(4)
Appendix C: Table of Risk 361(2)
Appendix D: Relating NPP and E/M Levels of Care Compliance 363(4)
Appendix E: Importance of Adhering to E/M Compliance With Electronic H&P 367(8)
Appendix F: Sample Electronic H&P Screens and Forms 375(14)
Appendix G: Sample Forms for EHR Evaluation 389(10)
Appendix H: Benchmarks for EHR Design and Functionality 399(2)
Appendix I: Practical EHR Axioms 401(4)
Index 405