The Endangered Medical Record: Ensuring Its Integrity in the Age of Informatics

, by Slee, Vergil N.; Slee, Debora A.; Schmidt, H. Joachim

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ISBN: 9780961525521 | 0961525525
Cover: Paperback
Copyright: 4/1/2000

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A pioneer in medical informatics, Slee warns that the impending nationwide conversion from one diagnosis coding system to another is merely another cliff in the plummeting quality of information in the medical industry. He details the forces that erode data quality and cause the loss of valuable clinical information, and poses solutions based on scientific principles, experience, and medical literature.

List of Figures	p. v
Foreword	p. vii
Preface	p. xi
Overview
Abstract	p. 2
Four Serious Flaws in Our Health Information System	p. 3
Your Personal Medical Record	p. 5
Code-Dependency in Health Information	p. 8
The "Four Flaws"--Where the Problems Are	p. 12
The Solutions: Living With "Code-Dependency"	p. 26
The Time Challenge	p. 34
A Great Opportunity	p. 41
History and Background
Medical Records, Coding, and Healthcare Classification	p. 43
Primer on Medical Records	p. 45
Formation and Contents	p. 46
Uses of Medical Record Information	p. 50
Health Information Professionals	p. 53
The Electronic Medical Record (EMR)	p. 60
Expression of Clinical Concepts	p. 71
Types of Language	p. 71
Uniformity in Clinical Language	p. 77
Language Can't--and Shouldn't--Be Controlled	p. 97
Retrieval of Medical Record Information	p. 99
Access to Information	p. 100
Hospital Discharge Abstract Systems	p. 103
Codes and Coding	p. 117
The Code: An Information "Identifier"	p. 118
How Classifications Get Their Codes	p. 121
Coding Processes	p. 122
Maintaining Data Integrity	p. 130
Classifications and Classifying	p. 133
The Classification: An Information "Organizer"	p. 134
Attributes of a Classification	p. 135
Patient Information for Classifications	p. 139
The Process of Classifying	p. 144
Diagnosis Classifications	p. 149
The Early Years Using SNDO	p. 151
The International Classification of Diseases	p. 155
The Tenth Revision of ICD	p. 166
Procedure Classifications	p. 175
History	p. 175
Procedure Classifications for Hospital Use	p. 176
Procedure Classifications for Physician Use	p. 179
Toward a Single Procedure Classification	p. 188
ICD-10-PCS -- A New Coding System	p. 191
How We Code Today: Category Coding	p. 205
How "Category Coding" Works	p. 205
Walking Through: Coding "Polyneuropathy" with ICD-9-CM	p. 206
Examples from the Real World	p. 216
Problems and Solutions
Getting the Most from Our Health Information System	p. 223
Preserving Truth in Medical Records	p. 225
The "System" Encourages Distortion of Information	p. 225
The Impact on Physician -- and Patient	p. 232
The "System" Should Back Off	p. 236
Optimizing the Electronic Medical Record	p. 237
Getting the "Whole Truth"	p. 238
Designing the EMR to Improve Patient Care	p. 244
Increasing Security	p. 245
Standards for Health Information	p. 247
Capturing the Clinical Detail	p. 257
We Aren't Getting Enough Information	p. 257
Introducing "Entity Codes"	p. 260
The Path to Coding	p. 261
Entity Coding	p. 277
What Are Clinical Entities?	p. 277
Entity Codes	p. 279
How to Implement Entity Coding	p. 282
The Entity Coding Process	p. 286
Features of Entity Coding	p. 289
Living Successfully with Code-Dependency	p. 291
Decoding Healthcare Codes	p. 291
The Missing Link in Our Medical Knowledge	p. 297
Making Meaning Precise	p. 303
Standards for Keys	p. 313
Markup Language May Hold the "Key"	p. 314
Expanding Classification Possibilities	p. 317
Opening the Door for Multiple Classifications	p. 319
Entity Code Classifying	p. 320
The Joys of Entity Code Classifying	p. 324
The Challenge of ICD-10	p. 329
Consequences of Change	p. 329
How to Buy Time	p. 334
A New Beginning	p. 337
The Power of Codes	p. 337
Looking at Where We Are	p. 339
The "Wish List"	p. 340
Saving the Medical Record	p. 341
The Bottom Line	p. 343
Coding Systems
International Classification of Diseases	p. 347
Introductions to ICD-6 and ICD-9	p. 364
Standard Nomenclature of Diseases and Operations	p. 407
Diagnosis Related Groups	p. 421
Unified Medical Language System	p. 425
SNOMED International	p. 429
NHS Codes (Read Codes)	p. 459
International Classification of Primary Care	p. 473
Index for Radiological Diagnoses	p. 483
Index for Radiological Diagnoses, Computer Version 4.1	p. 489
Mortality Medical Data System	p. 491
Medcin	p. 497
Other Resource Materials
ICD-9-CM Classification of the Circulatory System	p. 515
NCVHS - 1993 Annual Report	p. 533
Coding Resources	p. 551
Bibliography	p. 557
About the Authors	p. 585
Colophon	p. 589
Index	p. 591
Table of Contents provided by Syndetics. All Rights Reserved.

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The Endangered Medical Record: Ensuring Its Integrity in the Age of Informatics

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