Electronic Medical Record
Posted: Monday, October 13, 2008
by Rose-Marie Chaperon
Chaperon Consulting, LLC
An electronic medical record (EMR) is a medical record in digital format. In health informatics an EMR is considered by some to be one of several types of EHRs (electronic health records), but in general usage EMR and EHR are synonymous. They can also be described as an automated, on-line medical record containing clinical and demographic information about a patient that is available to providers, ancillary service departments, pharmacies, and others involved in patient treatment or care. There are many advantages to having an EMR system. EMR does not interfere with Doctor-Patient Relationship, computer word processor versus pen with paper. There is no difference in patient satisfaction. The computer does not degrade the clinical encounter. It does not perceived to make encounter impersonal finally yet importantly, it is not perceived to divert attention from patient and does reduce confidentiality. There are many companies out there, who offer EMR products, after much research, these companies are synonymous in cost in implementation requirements.
The process involved in conversion of these physical records to EMR is an expensive, time-consuming process, which must be done to exacting standards to ensure exact and accurate capture of the content. Because many of these records involve extensive handwritten content, some of which may have been generated by any number of healthcare professionals over the life span of the patient, there exists a high probability of some of the content being illegible following conversion. In addition, the material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. Consideration should be given to developing a procedure to sample and verify images at a high ratio to determine the accuracy and usability of the scanned images prior to disposal of the physical records, if they are disposed of at all.
As with any new system there are major concerns, is there adequate protection of privacy of the individuals whose records are being managed electronically. This class of information (in the US ) is referred to as Protected Healthcare Information (PHI) and its management is addressed under the Healthcare Insurance Portability and Accountability Act (HIPAA) as well as many State-specific privacy laws. The organization/individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties.
Can Electronic Medical Record Systems transform health care? It will be proven that EMR can improve patient safety, Release of Information and overall healthcare operation. Electronic medical records are probably more secure than the paper record we used to have, in the 21st century, EMR is the way of the future.
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