Electronic_Medical_Records

Electronic Medical Records MEDICAL-RELATED TECHNOLOGICAL INNOVATION ELECTRONIC MEDICAL RECORDS SYSTEMS INTRODUCTION COMMUNICATION AND INFORMATION TECHNOLOGY The past years have brought varieties of new technologies for communication that can potentially enhance health care . One of the most promising technology , and has the most extensive capabilities , thus the greatest potential for enhancing quality of care for patients is the electronic medical record (EMR . This will examine EMR , a term that is synonymous with computer-based patient record or electronic health record often used to refer to an electronic health record in a physician office setting or a computerized system of s rather than individual data elements . Furthermore , this will analyze EMR 's efficiency and effectiveness advantages and disadvantages impact on consumers and financial impact on organizations both long and short term . In addition , this will also identify any technology improvements that could still be made in the future with this technology , and will make appropriate recommendations ELECTRONIC MEDICAL RECORD Although electronic records management has been around for a number of years , it is still in its early stages in the medical community according to healthcare consultants and providers . Healthcare is moving slowly to adopt electronic medical records . Potential benefits of electronic records were acknowledged by healthcare providers and consultants years ago . Due to the expense of those systems , many healthcare providers have taken a long look at the technology before making the decision to implement it (Britt , 2007 . An electronic medical record (EMR ) is a medical record in digital format . Electronic medical record keeping facilitates access of patient data by physicians at any given location ,accurate claims processing by insurance companies ,building automated checks for drug and allergy interactions ,clinical notes and laboratory reports .The term electronic medical record can be expanded to include systems which keep track of other relevant medical information . Although an EMR system has the potential for invasion of a patient 's medical privacy ,EMRs can serve a great purpose when monitored effectively (US Code of Federal Regulations ,2005 EFFICIENCY AND EFFECTIVENESS Five levels of an Electronic HealthCare Record (EHCR ) keeping can be classified as follows 1 .The Automated Medical Record ,which is a -based record with some computer-generated documents . 2 .The Computerized Medical Record (CMR which makes the documents of level 1 electronically available . 3 .The Electronic Medical Record (EMR ) which restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems .4 .The Electronic Patient Record (EPR ) which is a patient-centered record with information from multiple institutions .5 .The Electronic Health Record (EHR ) adds general health-related information to the EPR that is not necessarily related to a disease . The development of standards for EMR interoperability is vital because of the fact that without interoperable EMRs , practicing physicians , pharmacies and health care institutions cannot share patient information , which is necessary for timely patient-centered care (US Code of Federal Regulations ,2005 ADVANTAGES AND DISADVANTAGES Although the issue of the privacy of patient records has received due attention in the last two years with arguments that Electronic medical records presents new threats to the privacy of patient-identifiable medical records , The Health Insurance Portability and Accountability Act of 1996 paved ways to protect the privacy of medical records Thus , any violation on these lines will be violation of the basic law . Under data protection legislation and the law in USA , the responsibilty for patient records in any form including films and tracings from diagnostic imaging procedures such as x-ray , CT , PET , MRI ultrasound , etc . lies always on the creator and custodian of the record , who is usually a health care practice facility and the patient owns the information within the record and has a right to view the originals , and to obtain copies under law . An Electronic medical record can be invaded instantaneously by someone with access to the data system and the password (Lzhrum , 2003 . Access to medical record not only invades the privacy but also gives room for complicated medical litigations . There have been reports of wrong identification of patients due to human and system generated errors in complex medical procedures like blood transfusions leading to death . Digital signatures are not as safe as signatures and further the records do not have a physical existence as with the other legally viable documents IMPACT ON CONSUMERS As per existing US laws ,a number of documents that have to be recorded ,preserved and made available to the patients on demand . The documentation includes , 1 .Diagnosis and Treatment Report which very Health Care delivery center today provides to the patient on the details of the diagnosis of the disease with follow up instructions , the Medicine information and the allergy reactions that could follow dietary restrictions , dos and don 'ts , restrictions and exercises prescribed . This documentation serves a key purpose in medical practice .2 .The Health Record which is the proper documentation of records of all treatments and medications , as well as a record of a patient 's reactions and behavior . The health record is the written and legal evidence of treatment . Careful and accurate documentation is vital for patient welfare and that of the doctor . Documentation includes medication administered , treatments done with date time , factual objective and complete data , with no blank spaces left in charting , on flow sheets or on check lists , calls made to health care team , client 's response , signature of the nurse in every entry and consent for treatment . 3 . Informed Consent , which is a document , recorded before any terminally ill person receives his chemotherapy or an invasive procedure . The patient or his /her health attorney should give a well-documented informed consent before such procedures . Informed consent means that tests , treatments and medications have been explained to the person , as well as outcomes , possible complications and alternative procedures . Any medical hospital can be pushed into a center of a litigation storm after allegations without informed consent .4 .Medical Billing and Insurance , which are part of the health care system in USA . These documents are now available to the consumers on demand anywhere and anytime FINANCIAL IMPACT The National Academy of Sciences report states that the health care industry spent between 10 and 15 billion on information technology in 1996 . But the cost of EMR keeping has drastically come down on account of technological innovations discussed . Recently , RED medic Inc , a California based firm has introduced a cheap online medical record service with an annual membership of just about 35 .The company Web site collects , stores and gives access to everything ever wanted by health-care professionals to know about a patient 's medications allergies , immunizations , conditions , doctors , emergency contacts and insurance providers . The system also stores and transmits more complex information such as advance directives , EKGs and other essential medical documents and diagnostic imaging techniques . This health information service is capable of delivering information to any doctor or hospital anytime , within the United States TECHNOLOGICAL IMPROVEMENTS There are many standards relating to specific operation of EMRs in the USA and across the globe . These include ASTM International continuity of care record ' in which patient health summary is based upon XML ANS1 X12 ,which is a set of protocols used for transmitting any data including billing information CEN ,which is the European Standard for EMR DICOM ,A popular standard in radiology record keeping and HL7 ' which is commonly used in clinical document architecture applications .There are many software programs specially developed for electronic record keeping . This includes `Doctors partner , an advanced Electronic Medical Records (EMR ) System with Integrated Appointment Scheduling Billing , Prescription Writer Transcription Module , Document Management and Workflow Management built to meet HIPAA standards . `Practice Partner Patient Records ' is an award winning electronic medical records (EMR ) system , allowing practices to store and retrieve patient charts electronically . There are innumerable such branded medical record soft wares available today (Ringold et .al 2000 RECOMMENDATIONS Electronic medical record system is a boon to the medical sector as well as the patients if utilized in the right perspective . Electronic medical record system should give scope for better treatment options and in fact better treatment . This should facilitate physician access to the patient case history beyond the geographical and time barriers with the advent of the Internet and make the whole process of medical care simple with the patient medical record available to any authorized physician at any given location and time . The system should also minimize healthcare costs with reduced diagnostic procedures in the healthcare process CONCLUSION Scientific and social changes of the 21st century have brought a radical change in the Health care delivery system with excellent technological innovations . One such innovation is the Electronic Medical Record System REFERENCE . Hallvard Lzhrum , MD , Tom H . Karlsen , MD , and Arild Faxvaag , MD , PhD Effects of scanning and eliminating based medical records on hospital physician 's clinical work practice . Journal of the American Medical Informatics Association 10 : 588-595 . 2003 . Medical Board of California : HYPERLINK "http /www .medbd .ca .gov /Complaint_Info_FAQ_Records .htm " \o "http /www .medbd .ca .gov /Complaint_Info_FAQ_Records .htm " Medical Records - Frequently Asked Questions . Ringold , JP Santell , and PJ Schneider " HYPERLINK "http /www .ajhp .org /cgi /content /abstract /57 /19 /1759 'maxtoshow HITS 10 hits 10 RESULTFORMAT searchid 1 FIRSTINDEX 0 sortspec relevance volume 57 firstpage 1759 resourcetype HWCIT " \o "http /www .ajhp .org /cgi /content /abstract /57 /19 /1759 'maxtosh ASHP national survey of pharmacy practice in acute care settings : dispensing and administration--1999 . American Journal of Health-System Pharmacy 57 (19 : 1759-75 . 2000 . US Code of Federal Regulations , HYPERLINK "http /frwebgate .access .gpo .gov /cgi-bin /get-cfr .cgi 'YEAR current TITLE 45 PART 164 SECTION 501 SUBPART TYPE TEXTPrivacy " \o "http /frwebgate .access .gpo .gov /cgi-bin /get-cfr .cgi 'YEAR current TITLE 45 PART 164 SECTION 501 SUBPART TYPE TEXTPriva of Individually Identifiable Health Information ' Title 45 , Volume 1 ,October 1 , 2005 PAGE PAGE 2 Electronic medical Record ... Read more: http://www.mightystudents.com/essay/Electronic.Medical.Records.37140#ixzz1kD8BpW2e