Medical informatics is commonly defined as computer applications in medical care. The longer definition can include biomedical informatics which is an emerging discipline that is the study, invention and implementation of structures to improve communication, understanding, and management of medical information.
The goal of biomedical informatics is the integration of data, knowledge, and tools necessary to use that information in the decision making process involving patient care. An expert on medical informatics, J.H. Van Bemmel says that this division of medical technology “comprises the theoretical and practical aspects of information processing and communication based on the knowledge and experience derived from processes in medicine and health care”.
The applications can be divided as follows:
- Computerized patient records
- Decision support systems
- Signal processing – ECG, electroencephalography (EEG) electromyography (EMG)
- Image processing – Radiography, CT scanning, MRI/magnetic resonance etc.
Our company focuses attention on the first item, EMRs or computerized patient records. Complete and accurate clinical documentation is a critical component of the care process. Medical records serve as an organizing structure for clinical decision making, a tool for communication to other providers, and a process for proper recall to accurately bill for services.
Medisoft Clinical’s problem list includes major and minor problems or other problems, risks and hospitalizations. The risk list can provide valuable insight to a patients symptoms especially if it is accurately updated according to the patients past and family medical history. Recurring hospitalizations can also offer clues to the most appropriate course of care.
The ability to create a coded problem list is a requirement for all certified EHR systems and problem documentation is an element of Joint Commission requirements as well. Meaningful Use regulations mandate that physicians must document a coded problem (or structured entry indicating that the patient does not have any problems) for at least 80% of their patients in order to qualify for the substantial incentive payments. Because an accurate problem list can help a physician track a patient’s status and progress, it follows that there will be fewer omissions in care and will streamline clinical reasoning and documentation.
Recent research confirms that patients who have accurate and complete problem lists receive better care than those who do not. There are other reasons the problem list can be valuable. Electronic problem lists can generate diagnosis-specific registries and the decision support systems are only useful when an accurate clinical problem list is supplied.
Integrating the problem list into a doctor’s workflow is a matter of individual preference. Some EMR users prefer to review the list at the beginning of the encounter. Others might read the list either before or during the patient visit. As they work through the problem list they can ask questions while updating the record problem by problem. We will explore other areas of the EMR in future posts.
Iron Comet Consulting is a Mckesson Platinum certified reseller, medical IT firm and medical billing service based in Stockbridge, Georgia. Our products combine the clinical with the financial to improve workflow and revenue capture. Mckesson’s Medisoft Clinical is a complete physician practice optimization solution. For more information, please visit http://www.ironcomet.com