Topics in health record management最新文献

Designing a clinical information system offers a sense of accomplishment similar to that of a dramatic performance. The development of the data dictionary and proposed system description requires the same attention to detail as stage directions in a script. The people involved in daily system operation are of key importance in developing a clear understanding of how things actually happen in the information flow and decision process. Once the business rules are defined and edits and conditions are developed to ensure data integrity, it is time to step back and let the performance begin. The real power of the user-designed system, like that of a performance before a live audience, comes with the ability to query the data for answers to issues and problems decision makers did not face at the time of the initial system design.

Federal and state enforcement agencies have increased their scrutiny of hospitals to make certain they are complying with anti-dumping law. Medical record practitioners can assist their institutions by providing policies that require appropriate documentation of compliance. Given the potential sanctions imposed by anti-dumping laws, these policies should be reviewed carefully by hospital administrative, medical, and legal personnel.

Consider data as content, as the parts required for building "something." But data alone are not the something. Data are a part, not the whole. Consider information as context. It is akin to having the something. But information is dependent on data for building the something, the whole. Thus, translating data into information requires being aware of and respecting the content and context relationship and dependency of data and information. Finally, translating data into information requires an understanding of people and how people communicate. Data and information are effective means for people to express, exchange, and communicate ideas. When data and resulting information communicate to and inspire people, ideas originate. Thus, data and information are essential for communication to occur and function as the origin of ideas of the future.

The purpose of this study was to determine whether the actual and appropriate roles and functions of medical record practitioners varied by credential, current position, years of medical record experience, and size of facility. The actual role describes what practitioners are currently doing in the workplace; the appropriate role describes what practitioners believe they should be doing in the workplace. For both the actual and appropriate roles, current position was the most discriminating variable, and credential was the least discriminating variable. Lack of discrimination is most likely due to the similarity in the professional components of medical record administration and medical record technician educational programs.

All the health care facilities examined in the case studies addressed several important organizational issues before and during the installation of their systems. All the facilities examined employee commitment. The prudent managers considered how easily their employees adapt to changes in their jobs and work environment. They considered how enthusiastic cooperation can be fostered in the creation of a liberated and reengineered office. This was determined not only by each individual's reaction to change, but also by the health care facility's track record with other system installations. For example, document image, diagnostic image, and coded data processing systems allow the integration of divergent health care information systems within complex institutions. Unfortunately, many institutions are currently struggling with how to create an information management architecture that will integrate their mature systems, such as their patient care and financial systems. Information managers must realize that if optical storage technology-based systems are used in a strategic and planned fashion, these systems can act as focal points for systems integration, not as promises to further confuse the issue. Another issue that needed attention in all the examples was the work environment. The managers considered how the work environment was going to affect the ability to integrate optical image and data systems into the institution. For example, many of these medical centers have created alliances with clinics, HMOs, and large corporate users of medical services. This created a demand for all or part of the health information outside the confines of the original institution. Since the work environment is composed of a handful of factors such as merged medical services, as many work environment factors as possible were addressed before application of the optical storage technology solution in the institutions. And finally, the third critical issue was the organization of work. "Organizations that understand their business processes are having no trouble whatsoever justifying the cost of optical storage-based information management systems," said Thornton May, director of imaging research at Nolan Norton Institute. "It is only confusing to organizations that do not have a feel for what is happening in the flow of work in the company. If an organization has on-line performance measurements with regard to time, cost, quality, error rates, and customer service, the move to optical image and data management technology is a no-brainer."(ABSTRACT TRUNCATED AT 400 WORDS)