Electronic Health Record - The Biggest Contribution to Healthcare
Discovery of
medicines and medical science is the biggest event in the history of mankind.
From ancient times till few centuries back the patients were treated successfully
by the physicians, but there were hardly any records available for every case
they handled and every aspect of that case. We have lost that data, which could
have been helpful in the modern medicine world. Many special treatments given
for particular symptom, any different kinds of techniques used while treating
the patients or any new type of medicinal formulas have gone under the cover of
undocumented history. When we understood the need of recording the data in
healthcare sector, it gave rise to different types of medical records.
Earlier these
records were mostly handwritten. Slowly the report typing system was
introduced. We faced multiple disadvantages with this type of medical records.
- There was no copy of the records, so
if the record gets misplaced/damaged there is no backup for the data.
- Handwritten documents were many a
times illegible, so the data extracted from those documents was partial.
- Damaged handwritten documents used to
get fade up, which was again a problem in integrity of the data.
- Archival
of those records was a big task.
- Handling those records was difficult.
- For
any purpose those documents were needed to get reorganized manually.
- As it was based on manual activity,
most of the times the data on the actual record was incomplete.
- There was limitation for data
capturing due to dependability on type of data (graphical reports were
difficult to capture as a medical record).
- Portability of the documents and
transferring data to the other center was a headache.
- Records
were misplaced multiple times and no copies were available for the same.
- During that period the importance of
the medical data was not very well understood and therefore medical data
privacy and ethical practices were not much implemented for any medical
records.
- Data
capturing on timely basis was time consuming and difficult for the
healthcare professionals.
Electronic
Health Records
IT Field extended
its tools to help medical domain in solving these problems. This has given rise
to the concept called Electronic Medical Record, widely
accepted and practiced these days and also known as EMR. This brought
revolution in the field of medical data handling.
Adding medical data
for any patient on computers, storing it in the small hard drive, reviewing the
same data again and again, easy updating and editing the data are few of the
key benefits this system has provided to us.
Types of
EMR:
Medical health
records start with entering the patient with his/her specific ID numbers to the
computer. Adding history of the patient including social, family, past medical,
surgical history and medicinal history generates initial intake report, which
is used and updated every time the patient visits the center.
- Various office notes, chart notes,
therapy notes generated date wise provide detailed information of the
treatment flow of that patient.
- Operative reports, nurse’s reports,
assessment and flow sheets, discharge summaries provide accurate data for
every minute spent during hospital admissions. These also include various
graphs, which add value to the data. They are also system generated and a
part of medical health record.
- Ante-partum records, birth records,
development records, death records and also postmortem reports has their
own importance.
- Various
MRIs, CT scans, laboratory studies, x-rays and other diagnostic studies
are reported via electronic medical records only.
Advantages
of EMR:
- Data can
be stored and can be reviewed multiple times, got rid from pills of files.
- Editing
and updating the data is easy.
- Electronic
capturing system forms make sure that the data is complete and with the latest
technology we can be sure about the integrity of the data.
- Medical
data privacy and ethical practices can be very well implemented as part of
HIPAA privacy rule.
- Secured
portability of the data is possible using this latest technology.
- Damage
to the data is very rare and can be corrected easily.
- Illegible
data is no longer a problem.
- Archiving
a large amount of data is cost effective, safe and easy.
- Reduced
data capturing time.
- Very easy to handle and generate.
- Require less space.
- Reorganization of the medical records is
very easy.
Scope of
EMR:
All the leading
countries and developing countries are using EMR in their day-to-day medical
data capturing.
1. Past records are required in deciding
current treatment.
2. Analyzing the effectiveness of drugs in
drug development.
3. In insurance/claim processing.
4. In deciding disability status.
5. For any medico-legal actions.
6. As a part of police investigation.
7. Employment scanning.
8. Drug dispensing and monitoring systems.
9. Auditing research and evaluations.
Laws for
EMR:
The laws, rule and
regulations change in every country for
- Accessibility
- Privacy.
- Ownership.
- Archival period.
- Destruction of EMR.
EMR indeed is a
bestowal as it has improved the quality of healthcare services and healthcare
professionals can now focus more on the core work by spending very minimal time
and energy on EMR.
To know more about EHR
or medical record summarization, you
can mail us on info@itcubebpo.com or you can call us on +1 (614)
434-2376.
