The General Accounting Office of the Information Management and Technology Division reported the need for a standardized coding system due to the frequent use in medical practices of the same term for various ailments; such as describing hepatitis as a liver inflammation (GAC, 8). “The use of different terms and codes…to indicate the same condition…complicates retrieval and reduces data reliability and consistency.” (GAC, 9) Coding systems for electronic record keeping differs from coding systems utilized in medical billing primarily because billing code sets are too generalized to offer specific information about a condition or diagnosis (Gartee, 64). Ideally, information entered into an electronic medical record should be standardized amongst all facilities, no matter the software system or user which is the basis for using a universal system of codes (Bowman). Read the rest of this entry »
Electronic Medical Records and Coding Systems
5 05 2010Comments : 26 Comments »
Tags: coding systems, College of American Pathologists, Cornell, David Brailer, Electronic Health Record Association, electronic medical records, electronic records, EMR software, General Accounting Office of the Information Management and Technology Division, Harvard, International Health Terminology Standards Development Organization of Denmark, interoperability, Johns Hopkins, MEDCIN, medical billing, National Coordinator for Health Information Technology, National Library of Medicine, physician’s medical language, SNOMED-CT, Systematized Nomenclature of Medicine-Clinical Terms, UNC Health Sciences Library, United States Department of Defense, US Department of Health and Human Services
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Key goals and realization of EMR implementation
1 05 2010The purpose behind moving to electronic medical recordkeeping is “to create an interoperable national system for the secure exchange of healthcare information”, explains Dr. Bill Crounse (Crounse). When former President George W. Bush announced in his January 2004 State of the Union speech his goal for the United States to be utilizing electronic medical records by 2014, he stated that “by computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” Read the rest of this entry »
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Tags: aaron dunkel, american recover and reinvestment act of 2009, benjamin geisler, bill crounse, brad eichhorst, clarence jernigan, computerizing health records, daniel pallin, david blumental, deborah covington, ehr, ehrs, electronic health record, electronic medical records, emr, george w bush, H.R. 3014--111th Congress, healthcare, hospitals, implementation of electronic medical records, information, james lenhart, jan biles, january 2004, jeremiah schuur, julie dostal, kansas department of health, karen honess, kathleen dahlkemper, kevin johnson, kevin roper, mark knox, matt murray, physician's offices, president, recordkeeping, richard benedetto, sharon mclane, Small Business Health Information Technology Financing Act emrs, software systems, staff attitudes, state of the union, todd swanson
Categories : School Research Papers