In the age of the internet and rapid developments of information technology, the way we view, edit, and exchange documents is changing and becoming more and more advanced.
What is a medical record?
A medical record is very important in the medical field as it is a reference to each patient with valuable information about the patient. It includes such basic things as the patients name, address and date of birth. The medical record is essentially a history of each patient and contains documentation regarding the patient’s former symptoms, diagnosis and treatments. Medical records were usually kept independently with each healthcare provider that the patient was associated with.
Paper-based medical records require a lot of time, space and effort to maintain, store and organize. Another disadvantage to the paper-based medical records is that all notes taken on them are usually handwritten which allows for confusion on possibly important issues due to a legibility problem. While medical records are very important, they do have a few problems that need to be worked out to make them even more useful then they were originally intended to be.
Why should we have Electronic Medical Records?
Because medical records are so important to a healthcare provider when responding to a patients needs, more accurate and accessible information is a must. Initially, the cost to go from paper-based medical records to electronic medical records can be time consuming and costly but the benefits will greatly outweigh the costs in the long run. Taking the medical record to the digital world can have tremendous advantages over the traditional paper-based records of the past.
Why are Electronic Medical Records advantageous?
An electronic medical record may contain three or four essential sections. There may be a section that allows for free writing about each patient that the doctor can input whatever information he feels will be necessary later. There may also be a section where conclusions and any future plans can be entered and stored. There may also be a structured section which can contain data that is more template based (check boxes) or there can be controlled vocabulary by selecting certain medical terms from a dropdown list, or medical codes can be inputted. Since all of this data is stored electronically it will be clearly legible, neatly organized, and will allow for easy editing.
There is also another section that can be attached to the electronic medical record but it does not allow for free editing on it. I am referring to picture-related information such as charts, and graphs. Pictures can also come from other places in the form of letters and bio tests, etc. and can be attached to a patient’s medical record. Although picture related information cannot be edited directly there may be notes made regarding the information found in the image in another section referring to the image.
Another huge advantage to keeping electronic medical records is the ease of access and small storage space required. All patients records can be stored digitally on a server and entered into a database allowing for an incredibly fast way to find a particular patients record. Some software companies that specialize in electronic medical records even allow all patients medical records to be accessed securely from anywhere via the internet.
As you can see, medical records are very important and contain extremely pertinent information regarding each patient. With such an important record there needs to be an effective method to keeping these records organized, legible and easy accessible. All of this can be accomplished with electronic medical records.
Article Source: DirectoryM
Electronic health record
From Wikipedia, the free encyclopedia
This article is about shared or comprehensive computerized health-care records in enterprise-wide systems. For local computerized records in a specific health-care organization, see
Electronic medical record.
An electronic health record (EHR) (also electronic patient record or computerised patient record) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems. Such records may include a whole range of data in comprehensive or summary form, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, and billing information.
It is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office.
Its purpose can be understood as a complete record of patient encounters that allows the automation and streamlining of the workflow in health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting.
Reduction of cost
In the U.S. a vast amount of funds are allocated towards the health care industry—more than $1.7 trillion per year. If savings are allocated using the current level of spending from the National Health Accounts, Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year.
Improve quality of care
The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality.
EHR systems are claimed to help reduce medical errors by providing healthcare workers with decision support. Fast access to medical literature and current best practices in medicine are hypothesised to enable proliferation of ongoing improvements in healthcare efficacy.
Improved usage of EHR is achieved if the presentation on screen or on paper is not just longitudinal, but hierarchically ordered and layered. During compilation while hospitalisation or ambulant serving of the patient, easing to get access on details is improved with browser capabilities applied to screen presentations also cross referring to the respective coding concepts ICD, DRG and medical procedures information.
Computerized Physician Order Entry (CPOE)—one component of EHR—increases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.
Promote evidence-based medicine
EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices.
These benefits may be realized in a realistic sense only if the EHR systems are interoperable and wide spread (for example, national or regional level) so that various systems can easily share information. Also, to avoid failures that can cause injury to the patient and violations to privacy, the best practices in software engineering and medical informatics must be deployed.
Record keeping and mobility
EHR systems have the advantages of being able to connect to many electronic medical record systems. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure.
As of 2000, adoption of EHRs and other health information technology (HITs) (such as computer physician order entry (CPOE)) was minimal in the United States (outside of the VA system). Fewer than 10% of American hospitals had implemented HIT, while a mere 16% of primary care physicians used EHRs. In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system. In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in 2001. However, less than one-tenth of these physicians actually had a “complete EMR system” (with computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes).
The healthcare industry spends only 2% of gross revenues on HIT, which is low compared to other information intensive industries such as finance, which spend upwards of 10%.
Incentives
Until recently, with the American Recovery and Reinvestment Act of 2009, providers were expected to take the full risk of investing in healthcare IT. Notably, healthcare payers, such as the government through Medicare, also have potential for significant cost savings if providers adopt EHR systems.
The HITECH Act, part of the 2009 economic stimulus package (ARRA) passed by the US Congress, aims at inducing more physicians to adopt EHR. Title IV of the act promises incentive payments to those who adopt and use “certified EHRs” and, eventually, reducing Medicare payments to those who do not use an EHR. Funding for EHR incentives is also added to the Medicaid system. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to also show “meaningful use” of an EHR system.
Health information exchange (HIE) has emerged as a core capability for hospitals and physicians to achieve “meaningful use” and receive stimulus funding. Healthcare vendors are pushing HIE as a way to allow EHR systems to pull disparate data and function on a more interoperable level.
Meaningful Use
The meaningful use of EHRs intended by the US government incentives is categorized as follows:
* Improve care coordination
* Reduce healthcare disparities
* Engage patients and their families
* Improve population and public health
* Ensure adequate privacy and security
The Obama Administration’s Health IT program intends to use federal investments to stimulate the market of electronic health records:
* Incentives: to providers who use IT
* Strict and open standards: To ensure users and sellers of EHRs work towards the same goal
* Certification of software: To provide assurance that the EHRs meet basic quality, safety, and efficiency standards
The detail definition of “meaningful use” is to be rolled out in 3 stages over a period of time until 2015. Details of each stage are hotly debated by various groups. Only stage 1 has been defined while the remaining stages will evolve over time.
Start-up costs
In a 2006 survey, lack of adequate funding was cited by 729 health care providers as the most significant barrier to adopting electronic records. At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month (including the amortization of startup investment).Vendor costs account for 60-80% of these costs. There are exceptions. A November 2006 survey of a widely available open source EHR reported startup costs of only $1083 – $7500/provider and $67 – $750/month per provider.
Some proponents of EHR systems suggest that startup costs will be recouped within 3 years. A study of the effects of EHRs in primary care settings published in the American Journal of Medicine estimated net benefits from EHR use of over $86,000 per provider over a five-year period.
Some physicians are skeptical of such published cost-savings claims, however. They believe the data is skewed by vendors and by others who have a stake in the success of EHR implementation. Many are resistant to invest in a system which they are not confident will provide them with a return on their investment.
Brigham and Women’s Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.
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