A Computer Based Information Systems With Diagnostic Capabilities Have Been Developed For Medicine Essay

Recently has launched a network of 43 oncology sites, part of Quintiles Precision Enrollment (QPE), which combines their technology platform with electronic medical records so that they will only open sites when they have appropriate patients to meet protocol requirements.

The knowledge base for DXplain contains more than 65,000 relationships between diseases and patient descriptors (or clinical manifestations). The format for these relationships and the data structures are similar to the format and data structures used in the INTERNEST/QMR system except that in DXplain terms cannot only support a given diagnosis, but can also contradict other diagnoses. The relationships in DXplain are concerned with three different elements: 1) term importance, 2) term frequency and 3) term-evoking power. Term importance is used to express how significant the particular term is in indicating the presence of disease. A high term importance is given to findings that can be identified with high reliability or are rarely found

An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient

An accurate and specific documentation of universally accepted set of codes are important for the protection of healthcare providers as well as increased reimbursement for services received. These codes are for the validation of which services the patient received from their health care provider ( (Page, 2009). Having the correct codes in place insures the provider with the information needed by the health insurance carrier. Maintained by the AMA (American Medical Association), this universal numeric assignment is also used for developing guidelines for medical care review as well as data collection for medical education and research (Scott, 2013).

Technology today has revolutionized the health care realm, as technology evolves so does the environment promoting quality care for that in need. This presentation will explain multiple abbreviations needed to translate and describe AMR, CMR, CMS, along with CMS – 1500, and CPT. Also, explore the meaning of DRG, EPR, HL7, ICD – 9 codes, and UB – 92.

I like the approach internists have to the patient, attempting to diagnose using a sequence of physiopathology events and been as minimally

“… longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting”. Included in this information are patient demographics… reports. The EHR automates and streamlines the clinician 's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, and related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting.”(GAO, 2010)

Electronic retrieval of patient demographics, allergies, current medications, complete medical history, diagnostic and radiologic results, etc. occurs by clicking a few buttons. Electronic patient charts provide quick and easy access to physicians, hospitals, independent labs, and pharmacies. EHRs allow simultaneous access by independent providers and allow a collaborative effort for health care management of the patient. “EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians”. (Electronic Health Records Overview, 2011)

➤ Diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM

Common complaints like a sore throat is noted as one of the most common complaints for which individuals seek care. The ailment can be related to simple conditions like pharyngitis, laryngitis or tonsillitis but may be associated with more complex conditions and require the implementation of a thorough patient history and physical examination to provide both a timely and accurate diagnosis for the patient to promote optimum patient outcomes (Shepherd, 2013). The condition may also be related to pathogenic infections or environmental exposures (Ruppert & Fay, 2015). First and most importantly one must obtain a thorough history including information related to the onset of symptoms, duration and the severity of the condition, past medical history and current medication history because this information may account for 80% of the information related to the final diagnosis (Shepherd, 2013). Other criteria which must be obtained before diagnosis includes a review of systems during the history and physical exam of the throat, tongue, tonsils, neck and abdomen which includes identifying the presence of pertinent symptoms (Shepherd, 2013). Utilization of resources like the Centor score to determine the need for antibiotic

Electronic Health Records: Understanding and Using Computerized Medical Records, 2nd Edition, by Richard Garlee, Published by Prentice Hall, 2012, Pearson Education, Inc.

Electronic Medical Records or Computerized Medical Record System what is it and what are the advantages along with the disadvantages of using this system? That is what we will discuss in this paper.

The value of Clinical Decision Support Systems is having additional avenues monitoring patient’s data input. The Clinical Decision Support Systems are offering notifications of patient’s record data to specified department or medical personal.

Clinical decision-support systems (CDSS) apply best-known medical knowledge to patient data for the purpose of generating case-specific decision-support advice. CDSS forms the cornerstone of health informatics research and practice. It is an embedded concept in almost all major clinical information systems and plays an instrumental role in helping health care achieve its ultimate goal: providing high quality patient care while, at the same time, assuring patient safety and reducing costs. This computer based systems designed to impact clinician decision making about individual patients at the point in time that these decisions are made. If used properly, CDSS have the potential to change the way medicine has been taught and

Health Informatics created two main categories such as clinical and administrative information systems to meet the needs of one or more department within the health care organization. For the clinical information system, it is set to meet the needs in improving patient care. Therefore, the clinical information system (CIS) categories provide nurses information systems (NIS) that support the way nurses documents the care that given to the patients. However, to improve the delivery of nursing care, the healthcare organization must adopt a computer system that can successfully incorporate tools that will benefit nursing. There is two vendors’ software that implies these characteristics for the