What do you know about the Medical Record? For any lame individual it could be a collection of hand written notes or reports, usually written by a healthcare provider. These may be written by medical professionals such as doctors or nurses or even ancillary departmental staffs from laboratory, radiology or rehabilitative services. Such hand written notes are usually given to the patient and the hospital does not keep a record of the clinical event.
But at present, hospitals have started getting direct access to computerized databases that hold detailed clinical and non clinical information of all the patients it treats. These are called the Electronic Medical Records (EMR) or Health Information Systems (HIS). The Electronic Medical record is a computerized record which contains details of the care provided to a patient. A typical record would contain some of these details - patient’s identification and sociological data, admission notes, detailed history, acute and chronic illness, past investigations, immunization status, drug information and adverse reactions, progress notes, surgeries, operative notes, allergies, current medication, lab and radiological procedures and reports, medical education given to patient, transfer of health information, medical bills, third party details etc.
There is still an ongoing argument if patients and hospitals have benefitted from this change - of paper based systems to electronic health records. While paper based documentation systems show lower cost of maintenance and protect the confidentiality of a patient’s medical information, the EMRs are difficult to maintain due to cost of set up, installation and end user training. Also it has a constant threat of electronic theft and hacking.
With increasing technological trends and automation that has made it possible to capture, store and receive clinical data, many people have resorted to the use of electronic systems. We find many uses of the EMR to hospitals, patients and third parties such as…
Standardized reporting and abbreviations - which allows communication of health reports between external departments like medical billing and insurance
Legible data - that minimizes any form of medical errors on the patient
Orderly storage of data - that supports Clinical and Financial studies, student education, even medical audits and hospital planning that can help improve the quality of care provided by the hospital
Multiple point sharing - Data sharing between chain of hospitals that can reduced repetitive investigations at different hospitals or even reduce patient travel to a distant hospital
Reduced storage space - from Medical record department that store records for years to discs and films that occupy lesser space
Better transportation of patient data - through electronic transfer, with no geographical limitations
Detailed recording of all past visits of patient - better follow up and review
Biomedical equipments configured to the EMR - provide automatic data updates into the computer about patient vitals, ECGs, ultrasound scans etc.
Hospital managers have observed that even after the implementation of the HIS, many end users continue to follow manual recoding on paper, thus making the entire system a mixed form of documentation (were hospital used both written and computerized formats simultaneously). The most challenging part of an electronic system would be to overcome the resistance of healthcare professional towards computerized methods. Due to ease of writing on paper and medical professionals not being too computer savvy the implementation of the Electronic Medical Records has not been a complete success. There is still a long way to go before we covert from a paper to paper less medical record.