Topics in health record management最新文献

The Epidemiology Data Center at the University of Pittsburgh has developed a standard set of data management procedures, reports, and computing configurations for use on multicenter research projects. Based on budget restrictions and study design considerations, a project-specific data management system can be quickly constructed by utilizing appropriate components from the EDC tool kit: the PoP software system for the computerization of the database from paper forms to data entry screens; program shells for telecommunication and backup procedures; and procedural documents for providing the necessary training materials for centralized or decentralized processing environments. The EDC data flow specification provides quality control assurances from entry through statistical analysis.

In summary, having data from other service areas available in a relational clinical database could resolve many of the problems existing in today's registry systems. Uniting sophisticated information systems into a centralized database system could definitely be a corporate asset in managing the bottom line.

Pennsylvania has been successful in establishing a statewide cancer registry. The success of this registry results from the efforts of many different groups. The program has benefited from strong legislation making cancer a reportable disease and assigning the responsibility of reporting to hospitals. The PCR has implemented many initiatives to ensure that the cooperation of hospitals in operating the system is maintained, and that there is sufficient knowledge among hospital personnel to ensure complete casefinding. As the amount of statewide incidence data is increased over several years, the utility of these data for program planning and epidemiologic studies will increase greatly. The establishment and ongoing operation of the PCR ensure that cancer incidence data are available in providing answers to questions such as some of those asked following the accident at Three Mile Island.

A commitment to the maintenance of a comprehensive trauma registry can provide numerous benefits, both administrative and clinical. Uses of the information collected can vary in nature and scope based on the needs of the facility and the requirements of external regulatory bodies. Ultimately, the choice of data applications rests with the facility collecting the information. As the facility grows and evolves, so can--and must--its registry.

There is a lot of work yet to be accomplished through the scientific registry, which will be made more efficient by the consolidation of information into patient-specific files rather than the existing "file by form" set-up. Additionally, users will be able to input data directly, eliminating the problem of the time delays between transplant and follow-up dates and the actual use of the forms. The registry data also will become more useful as the database grows. The data on long-term graft and patient survival will directly influence future policy decisions and transplant practices. The clinical outcomes of transplantation also will be influenced by donor management and organ preservation techniques, all of which can be addressed through the use of registry data. The ultimate goal is to make transplantation more reliable, more predictable, more widely available, and less expensive. The national, comprehensive database accomplishes that goal.

The estimation of incidence (or risk) of disease depends on accurate and complete reporting of new cases and precise estimation of the population at risk. Therefore, incidence studies are often based on population-based incidence registries. A critical problem in diabetes research, however, has been the lack of adequate population-based data. For diseases that have a distinct and rapid onset, the best method of obtaining population-based data is to develop registries of community health information. These disease registries form an important tool for assessing the clinical course of diseases and can lead to an understanding of their etiology and pathogenesis. Moreover, by facilitating identification of cases, disease registries can serve as a population source for genetic and immunological testing, the results of which can be directly related to absolute risk. Evaluation of factors associated with a disease can suggest methods for reducing its incidence and even lead to its eradication. Such registries also permit the evaluation of existing or proposed health care measures. Registry information can rapidly be communicated to the local area health authorities to assist in altering patterns of care. Registries are therefore important for understanding the etiology and complications of chronic diseases as well as for evaluation of medical care in populations. For diabetes, and in particular, insulin-dependent diabetes, the development and comparison of registries in diverse populations worldwide may be more important than for other diseases. A major reason for developing them is that the disease is very costly both for patients and society.(ABSTRACT TRUNCATED AT 250 WORDS)

In 1986, Johns noted that "The hospital industry was caught unprepared for the external demands and information needs required in a case-mix reimbursement environment." Lack of a data-processing philosophy and inattention to external forces were cited as having hampered technology upgrade and integration of financial and clinical databases. The intervening years have witnessed a growth of information dissemination in the health care industry concerning information value and resource management. The frequency of appearance of articles on information management in the professional literature and the number of workshops and professional meetings addressing the topic attest to the current visibility of the information resource. Despite this flurry of interest, the industry has not developed its own models of information resources management nor validated its information evolution with accepted management information systems models. While interest in health care information resource management exists, understanding of the complex issues in this area has not developed as one would expect. While there are a myriad of reasons for this, a contributing factor is the lack of a research foundation for development and application of theory and models. Even though various graduate programs exist in medical informatics and biomedical computing, few concentrate on the study of health information resource management from an organizational perspective. Because of this, academic research in the area has been minimal. The scarcity of graduate-level programs has also meant that few individuals have been educated to deal with the challenges of managing the many disparate functional activities associated with health care information resource management. Due to a variety of internal and external forces, extreme demands were placed on the hospital information resource during the past decade.(ABSTRACT TRUNCATED AT 250 WORDS)

Information technology will continue to have a profound effect on decision analysis. Clinicians and technologists must continue to work together to achieve systems that enhance patient quality and managerial decision making. Users will continue to grow more sophisticated in using information systems for patient care and organizational analyses. Strategic information systems will not solve all problems that health care professionals may face. However, better decisions will result from improved availability of information. The acceptance, support, and imagination of power users will enhance and drive information system development and design. Strategic information systems will provide opportunities for data analysis enabling health care professionals to better support decisions.

It seems evident that both concurrent review programs and positive incentive programs have been implemented by a number of facilities in which little, if any, monitoring has occurred. Only half of the hospitals performing concurrent analysis provided statistics concerning the percentage of daily discharges arriving in the medical record department complete. Only one fourth of the hospitals provided information concerning the number of incomplete and delinquent medical records before and after the implementation of concurrent review. These data underscore the need for medical record administrators to evaluate the effectiveness of various strategies used to improve completion of medical records. Likewise, only a few of the hospitals that have implemented an incentive program for chart completion were able to provide all of the requested statistics concerning their chart status prior to and following the implementation of their programs. The results of the study indicate that numerous innovative procedures have been implemented in hospitals, with varying degrees of impact on the number of incomplete and delinquent medical records. The use of positive incentive programs in conjunction with punitive action is effective in helping to reduce the number of incomplete medical records.