Health Information Technology Medical Record Documentation Issues in the Electronic Era

作者：Dacey Bill^*; Bholat Michelle Anne

来源：Primary Care: Clinics in Office Practice , 2012, 39(4): 633-+.

DOI：10.1016/j.pop.2012.08.001

• Cloning
• Medical necessity
• Auditing
• Quality

This article outlines the regulatory movement propelling physicians into the electronic health record environment and the subsequent emergence of quality issues in the medical record. There are benefits and downside risks for implementing electronic health records as part of the desire of a practice or institution to build patient-centered medical homes. The intersection of how a practice or institution collects and reports quality metrics using health information technology and subsequently submits claims for services rendered has created unforeseen challenges for which leadership must be aware and address proactively.

• 出版日期2012-12