Topics in health record management最新文献

We look in one to three years to continuous speech recognition without sacrificing large vocabulary recognition or speaker independence. At that point we will lose some of the risk management value of structured reporting. But if the experience of emergency medicine is any indicator, it is clear that ASR is here to stay, and will increasingly become the gateway to the hospital information systems of the 90s.

The demands placed on medical record professionals can be overwhelming. However, these challenges present the opportunities to develop the new, exciting role of health information manager. The technologies and potential benefits are there. It is up to the medical record professional to make use of the opportunity.

As middle managers, medical record practitioners will be involved in justification of auto ID technology to upper management. To prepare a good justification, one must have a thorough knowledge of the technology and its advantages and disadvantages. One must also be familiar with the payback period and the installation process. This article has attempted to introduce the reader to some emerging technologies in health care, and answer some of the questions that are key to justifying their acquisition. By most estimates, these technologies are finding their way into health care, however slowly, and hold much promise for improvement in productivity and accuracy in data collection.

Using image scanning as a document capture mechanism at time of treatment or on day of discharge automates the medical record to achieve the larger objectives of simultaneous concurrent access to an electronic chart. This form of keyless document capture, although appearing labor intensive, is justified for improving business management and quality of care. Coupled with optical character recognition or barcode recognition for keyless data capture, medical information may be more easily made available for clinical research. Not merely a microfilm alternative, a medical record management system accelerates chart completion. Labor reduction is realized by eliminating filing and retrieval of active charts, loose sheet handling, photocopying, chart assembly, and chart location control. By reducing the reasons for chart completion delays, accelerated billing of Medicare accounts will occur, resulting in a reduction in receivables. Image-based document management systems accomplish the three things required of a senior manager in health care: (1) solve problems, (2) save money, and (3) make money.

Voice recognition is an exciting technology that is only starting to catch on in radiology. By reducing training time from days to several minutes, today's voice recognition systems are more practical than their predecessors. Voice recognition systems will improve the productivity of radiologists, allowing them to spend less time dictating their findings and more time concentrating on their specialty. Ultimately, the major benefit is increased patient care. As more and more hospitals become automated, voice recognition systems are a natural fit in this process. Radiology departments will be able to have integrated systems that will allow everything from initial patient entry, procedure status and tracking, and report dictation with voice recognition, to electronic report signature, report archiving, and patient billing.

The bar coding system has proven to be highly successful. Use of the bar code label has already been added to the dictation system in medical record and medical imaging services departments for entry of patient identification of each dictated report. Other system enhancements under consideration include tracking ancillary department reports as they are forwarded to the medical record department for storage in the permanent patient record and tracking individual volumes of a patient's medical record.

The literature concerning the diffusion of innovations reveals that it is not surprising that a promising technology is confronting obstacles in its development and implementation. Alternative technologies also often appear that address the same or similar problems. Better information enables physicians to provide medical care that is less expensive and less error prone. The prescription of medications is reduced in number and cost when the prescribing physician knows the current and previous medications of the patient. The ordering of clinical tests is reduced in number and cost, and the ordering of timely retesting is more likely when physicians have before them information about previous testing of their patient. The challenge is in how the portability of the patient card and its ability to be self-contained can enhance medical practice.

It is great to be able to say, if we had it to do over again, we would still do it.... But hindsight tells us we could have done some things better. We should have sinned bravely, and forged ahead with chart tracking in the main file room. The truth is, our inexperience with the technology made us overly cautious. We were, however, absolutely correct about the use of bar coding. Swift collection of accurate data is a treasure to be sought, bar coding is insurance of that treasure.

These policies and procedures accomplish two objectives. The most important objective is the protection of patient confidentiality. A secondary objective is to establish the hospital's reputation as an institution that cares about its patients and a place where celebrity patients can feel their confidentiality is secure. Failure to meet these objectives may expose the hospital to liability for breach of its patients' confidentiality and will certainly erode the hospital's reputation in its community.