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Doody's Review ServiceReviewer: David M. Liebovitz, MD (Northwestern Memorial Hospital)
Description: This book provides a practical framework to the complex process of implementing an electronic medical record. Useful nuggets are interspersed in many chapters and include items such as using structured text descriptions but not billing codes directly in physician notes to avoid downstream conflicts. The recommendations are drawn from the experiences of an integrated healthcare system and include key topics such as vendor selection, usability, primary and specialty practice differences, decision support, and optimizing inpatient care.
Purpose: The purpose is to serve as a practical reference for use in overcoming the challenges inherent in implementing an electronic health record. This is a needed and useful reference in that the experiences are generalizable to the many clinical practices currently using or planning to use a vendor based medical record system. The book meets the authors' objectives and contains many useful hints to incorporate during the initial part of the journey to implement an electronic health record.
Audience: According to the authors, the book is designed for the broad group of individuals tasked with implementing an electronic health record, including project team managers and directors, informaticians, consultants, and vendors. The authors are credible in terms of their real-world experiences and effective literature review.
Features: This book follows the process of planning for and then implementing an electronic record. Important hints for vendor negotiations and ensuring a reliable infrastructure (with design examples) are included. Training and support approaches and their evolution are described. Strategies for contending with the challenges posed by physicians and their pet software projects are included. Of great practical use for internal organization comparison are specific timing goals for online availability of various note types. The appendixes are useful for covering some common policy and procedural types of issues. A shortcoming of the book is the absence of more detailed examples of effective use of decision support. This would have been welcome as an appendix.
Assessment: This is an important book addition to the many articles describing the challenges of implementing various aspects of an electronic health record. A primary value of this book lies in the authors' experiences making design decisions while working with a vendor and how it's possible to balance competing demands while keeping the overall project focused on the clinical care benefits.