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Does Linguistic Obfuscation Exacerbate our Use Ambivalence?
[By Dr. Richard J. Mata; CIS, CMP™]
[By Dr. David E. Marcinko; MBA, CMP™]
The 2003 Institute of Medicine (IOM) Patient Safety Report [1] described an EHR [2] as encompassing:
- a longitudinal collection of electronic health information for and about persons;
- [immediate] electronic access to person- and population-level information by authorized users;
- provision of knowledge and decision-support systems [that enhance the quality, safety, and;
- efficiency of patient care] with support for efficient processes for health care delivery.
The IOM Report
A 1997 IOM report, The Computer-Based Patient Record: An Essential Technology for Health Care, provides a more extensive definition:
A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems).
The HIMSS Model
The EHR definitional model document developed by the Health Information and Management Systems Society (HIMSS, 2003) includes:
“a working definition of an EHR, attributes, key requirements to meet attributes, and measures or ‘evidence’ to assess the degree to which essential requirements have been met once EHR is implemented.”
The IOM Model
Another IOM report, Key Capabilities of an Electronic Health Record System [Tang, 2003], identifies a set of eight core care delivery functions that EHR systems should be capable of performing in order to promote greater safety, quality and efficiency in health care delivery:
8 Core Principles
Today, we realize that the eight core capabilities that Electronic Health [Medical] Records should possess are:
- — Health information and data. Having immediate access to key information – such as patients’ diagnoses, allergies, lab test results, and medications – would improve caregivers’ ability to make sound clinical decisions in a timely manner.
- — Result management. The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care.
- — Order management. The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed with which orders are executed.
- — Decision support. Using reminders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.
- — Electronic communication and connectivity. Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.
- — Patient support. Tools that give patients access to their health records, provide interactive patient education, and help them carry out home monitoring and self-testing can improve control of chronic conditions, such as diabetes.
- — Administrative processes. Computerized administrative tools, such as scheduling systems, would greatly improve hospitals’ and clinics’ efficiency and provide more timely service to patients.
- — Reporting. Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance.” [3]
Assessment
With all the confusion surrounding terms like quality improvement and “meaningful use” which can mean major Federal dollars to the coffers of a medical practice, clinic or hospital; are we still confused about basic definitional terms?
And, does eMR linguistic obfuscation exacerbate our use ambivalence and encourage physician/dentist eMR avoidance?
Conclusion
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References:
[1] See http://www.himss.org/content/files/PatientSafetyFinalReport8252003.pdf.
[2] EHR (electronic health record) is often used interchangeably with EMR (electronic medical record). In this discussion, EHR will be used consistently.
[3] See http://www.iom.edu/.
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Filed under: Glossary Terms, Information Technology, Practice Management | Tagged: david marcinko, EHRs, electronic health records, electronic medical records, EMRs, health information technology, HIMSS, HIT, IOM, Richard Mata, www.healthcarefinancials.com | Leave a comment »
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