ELECTRONIC MEDICAL RECORDS

Electronic Medical Records

Electronic Medical Records

Introduction

There are many functions associated with patient health records. Not only is the record used to document patient care, but the record is also used for financial and legal information, and research and quality improvement purposes. There are advantages and disadvantages with the paper medical record, there are also advantages and disadvantages associated with the EMR. In addition, since an EMR is a fairly new concept, there will also be barriers and obstacles in the implementation of the EMR.

Advantages of EMR

The EMR has several distinct advantages over paper health records. One definite advantage is the fact that there qre increasing storage capabilities for longer periods of time. Also, the EMR is “accessible from remote sites to many people at the same time “(Young, 2000) and retrieval of the information is almost immediate. The record is continuously updated and is available concurrently for use everywhere. Information is immediately accessible at any unit workstation whenever it is needed.

Currently the paper record represents “massive fragmentation of clinical health information.” (Schloeffel et al., 2001) This not only causes the cost of information management to increase but also “fragmentation leads to even greater costs due to its adverse effects on current and future patient care” (Schloeffel et al. 2001).

The EMR can also provide medical alerts and reminders. EMR systems have some “built-in intelligence capabilities, such as recognizing abnormal lab results, or potential life-threatening drug interactions”. Research findings supporting diagnostic tests and the EMR “can link the clinician to protocols, care plans, critical paths, literature databases, pharmaceutical information and other databases of healthcare knowledge” (Young, 2000).

Another benefit to an EMR is that it allows for customized views of information relevant to the needs of various specialties. The EMR is “far more flexible, allowing its users to design and utilize reporting formats tailored to their own special needs and to organize and display data in various ways” (Dick, Steen, and Detmer, 2007).

As a management tool, the EMR can provide information to improve risk management and assessment outcomes. Today, reimbursement is based on outcomes therefore healthcare organizations must seek innovative ways to improve quality of care and outcomes while managing costs. An EMR can decrease charting time and charting errors, therefore increasing the productivity of healthcare workers and decreasing medical errors due to illegible notes. “Reduction of medical errors is the concern of the public at large, state legislators, healthcare providers, and many other health professionals” (Waegemann et al. 2003). There have been numerous stories about fatal mistakes occurring because of illegible notes written by physicians. EMRs “address a problem that has plagued medical staff very possibly since the first doctor put pencil to paper. Since “handwriting is instinctive, and therefore difficult to change” (Dobias, 2003) automated systems can help eliminate this problem. Although some systems may seem costly, the gains in efficiency far offset the costs. Chart chasing is eliminated, as is duplicate data entry of the same information on multiple ...