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Secondary Analysis of Electronic Health Records
This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable r...
Medical Records Use and Abuse
'This book provides the background and practical guidance for all those of us who face challenges for the way we handle medical records. Written by a lawyer and a clinical informatician it provides the fusion between the legal issues and the practical clinical ones. There are clear explanations of the current legal framework, set in the context of real-world applications; the more complex issues that have a significant impact on Policy are also dealt with in depth. The background to 'consent' and the impact that implied and explicit consent can have on the way records are collect and used is particularly well covered. This book has many audiences, all of whom will gain from the easily accessible information within it. Caldicott guardians, research ethics committee members, and all those researchers and clinicians who need to analyze patient information will have a particular need for this handbook. Patients and the public should use it to understand how their healthcare information is protected and used. Its arrival could not have come at a better time' Sir John Pattison, Former Director of Research, Analysis and Information, Department of Health, England.
The Computer-Based Patient Record
Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.
Registries for Evaluating Patient Outcomes
This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or ...
Electronic Health Record
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 developme...
Medical Records and the Law
Health Administration
Access to Medical Records and Reports
For hospital managers, doctors and other health care professionals, this book provides guidance on the legislation relating to the right of the individual to his or her medical records. Three sections cover: patient access; access and litigation; and professional confidence and disclosure.
New Perspectives in Medical Records
This book provides innovative practical suggestions regarding the production and management of medical records that are designed to address the inconsistencies and errors that have been highlighted especially in relation to national eHealth programs. Challenges and lessons that have emerged from the use of clinical information and the design of medical records are discussed, and principles underpinning the implementation of health IT are critically examined. New trends in the use of clinical data are explored in depth, with analysis of issues relating to integration and sharing of patient information, data visualization, big data analytics, and the requirements of modern electronic health re...
Key Capabilities of an Electronic Health Record System
Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and ...
Health Records in Court
This book is an essential tool for all healthcare professionals. An understanding of the law and the way in which it impacts upon roles, responsibilities and care is a vital component in everyday healthcare. Written in a clear and concise style, Health Records in Court provides practical legal advice by highlighting real-life healthcare case studies and workplace examples. It offers much-needed, clearly explained guidance for navigating the complexities and intricacies of medico-legal processes, practices and obligations - vital for every health professional who creates, adds to or maintains health records.
