Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Making a diagnosis
Choosing therapy
Communicating the plan
The impact of EHRs and technology on clinical decision-making
Slide content:How Much Detail, in What Form? Lawyers Regulatory agencies Data mining Clinical and outcomes research Quality and performance improvement Patient safety 13
Slide notes:There are still other audiences with whom the clinician may communicate. Although the hope is that it wont be necessary, there may come a time when lawyers examine the patient record to look for information that supports their client, and the clinician should keep this possibility in mind as he or she creates the record. Government and private regulatory agencies may use the medical record to determine whether the clinical processes of care are appropriate and for other various audits. Others may use the medical record in aggregate for data-mining purposes to learn about diseases, treatments, or practice patterns. Still others will use the record in aggregate to perform clinical or outcomes research, quality and performance improvement reviews, and patient-safety studies. A major challenge for the clinician is to create appropriate communications for all of these audiences at the same time. 13