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  1. 1. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012 A Study on Computerization of Medical Record at a Corporate Hospital Syed Murtuza Hussain Bakshi, Dr.Sesham Mayuri RajAbstract:- delivery. The study also focuses on detailsDespite the growth of health information about hardware, operational procedure andtechnology the medical encounters are still other important facts pertaining todocumented on paper based medical record computerization of medical records..Most paper based medical records which areused today may pertain disorganization,illegibility and inaccurate entries. The Key words: Medical record, Informationmedical record is an important tool Technology, Computers Technology.supporting quality in clinical care; it is todayused by personnel trained in differenthealthcare disciplines, working in differenthealthcare settings, on different sites and indifferent languages. There are commonfactors that impede the adoption of electronicmedical record which include start-up costs,initial weeks of using a new system, Systemscomplexities and other hindering factors. Thepurpose of the study is to identify the processinvolved in computerization of medicalrecords, examine the potential benefits ofcomputerized medical record and itscontribution for improving health care 1 All Rights Reserved © 2012 IJARCSEE
  2. 2. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012Introduction patient-centered record with information from multiple institutions. Electronic Health RecordDespite the growth of computer technology in (EHR) adds general health-related informationmedicine most clinical encounters are still to the EPR that is not necessarily related to adocumented on paper based medical record; disease (Waegemann C.P, 1996).this may lead to disorganization, illegibilityand inaccurate entries and sometimes loss of The health record is an important toolfiles (James L. Rogers and Olga M.Haring, supporting quality in clinical care. It is today1979).The traditional paper based record is used by personnel trained in differentstill used due to its familiarity to users, disciplines, working in different settings, onportability, ease of recording “soft” or different sites and in different languages.“subjective” findings and its brows-ability for These include: patients themselves and theirnon-complex patients. There is also a sense of appointed careers clinicians in therapeutic orownership of paper based records, due to their anticipatory care roles, groups of cliniciansbeing only one copy, which increases the working in primary or secondary care,sense of security. One effect of this paramedical colleagues working with thereassessment has been a burgeoning of patient, clinicians and clerical or research staffelectronic medical record system (Richard S. undertaking clinical audit or quality assurance,Dick et.al (I991), William R. Hersh (1995)). hospital , general practitioners ,healthcare managers and healthcare purchasers (healthWaegemann in 1996 has classified five authorities or insurers) undertaking qualitylevels of Electronic HealthCare Record assurance, healthcare planners at hospital,(EHCR) which can be distinguished as district region or national level, legal advisorsAutomated Medical Record is a paper-based for the patient or the clinician, clinicalrecord with some computer-generated researchers, medical students and medicaldocuments, Computerized Medical Record teachers, commercial product developers for(CMR) makes the documents of level one market research (e.g. the pharmaceuticalelectronically available, Electronic Medical industry),insurance companies for determiningRecord (EMR) restructures and optimizes the payment, health economists and journalists.documents of the previous levels ensuring Just as there will be many different parties byinter-operability of all documentation whom it is accessed the record can play manysystems, Electronic Patient Record (EPR) is a 2 All Rights Reserved © 2012 IJARCSEE
  3. 3. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012roles in the provision of care to individualsand to populations (Kathryn J. Hannah 2006).There are common factors that impede the Methodsadoption of EMR in practices they are early The study was conducted at a 550 beddedstart-up costs, the initial weeks of using a new tertiary care hospital which is operationalsystem, Systems complexities pose challenges from 1983 which is accredited by Jointin achieving interoperability, physicians spend Commission International and serving themore time seeing patients and using the new population of Hyderabad and Secunderabad.EMR, spend quite a bit of time preparing the The present study is exploratory in nature it issystem for use in their offices working for conducted to identify the process involved inlonger days, The physician or the office staff computerization of medical records, thewill have to set up screens, options, methods hardware details, architectural details,of documentation, and order entry, the examine the potential benefits of CMR and itsconfiguration of hardware and software, lack contribution for improving health careof data exchange. Predictions based on delivery. It is largely descriptive andstatistical models suggest that Health categorized as a non-experimental qualitativeInformation Technology has the potential to study. The data is collected through structuredassist in dramatically transforming the interviews which were conducted at ITdelivery of health care, making it safer, more department and medical records departmenteffective and more efficient in the future .The data is analyzed by Matrix Analysis(Michael R. Ripchinski and Dwight O. which is in the form of flow charts, diagramsEichelberger (2008)) and pictorially representation as well as written descriptions. 3 All Rights Reserved © 2012 IJARCSEE
  4. 4. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012Discussions  Deficiency in records is checked. In case of deficiency the recordsThe research work resulted in the following are clarified by the respectiveexplanation. specialty.  After discharge the complete  International Classification of Patient Record from inpatient, Diseases (ICD10Coding) is done outpatient and emergency According to the Disease and departments are sent to Medical Filing is Done Record Department.  Then the Record is kept in the  Then each Patient’s record which Medical Record Department Rack has a UHID number (Unique with a trace card and if needed it is Hospital ID) is assembled and used for Research Purpose by compiled as shown in Figure 1 Doctors and Students.Figure 1 How computerized medical records are generated at the hospital?  Computerization of medical record started in the year 1995.  The Computerization of Medical Record is done through 3 Tier Architecture of an Enterprise Hospital Information System. 1) Application Server 2) Database Server 3) Domain Server  The complete Computerized Medical Records system and all the operations of the Hospital are based on the Application Server 4 All Rights Reserved © 2012 IJARCSEE
  5. 5. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012 where all the functions with Hospital Information System) accessibility are carried out. Software. Database Server is the system  All the information is shared to a where all the data gathered through single server from any branch all the departments is accessed and through an authorized login ID. If retrieved. the main server goes down then Domain Server is the system where backup server automatically all the data is saved, stored at one switches on and it acts as main place. This server acts as a backup server and the process of storing of for all the data acquired through files is continued. different departments of the  The Unique Hospital ID (UHID) hospital. generated is unique for the patients All the Records are automatically all over India. stored in the database server (E.g.: UHID – department wise, whose backup is APJ1.0001471228)When the stored in the domain server which patient is admitted in the hospital is at IT department. he/she is given UHID as well as an The earlier software that was IP No.(Eg: IP73226) ,The supporting the operations in the Computerization of Medical MRD was Wipro based software Records provides safety and that had been replaced by Tata privacy to the patient’s health Consultancy Service software record; this is because of the solution Med Mantra. involvement and improvement of The In-charge person of respective Information Technology in the departments of the Hospital has Health Care Industry. access to the records. These  The computerized files are stored records can be accessed by the IP- in JPEG Image Format. Track-No given to the patient with respect to his/her last visit. Sharing within the hospital departments is done with the EHIS (Enterprise 5 All Rights Reserved © 2012 IJARCSEE
  6. 6. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012Figure 2 Process of  The Organization is using HP FlatbedComputerization of Medical Scanner to Scan the Patient MedicalRecords Records.  Before scanning the Medical RecordsFigure 2 the respective Doctor is asked to attest it with the signature. Then the files are Scanned and uploaded in the Database of EHIS which is based on the details of the patients.  Mere like an updated Computerized Medical Record, the manual records are stored in the Database EHIS Server in order to make it compatible and available from any department of the hospital.  The uploaded file can be retrieved as similar to the computerized medical record system, but the difference is the user will access the attached file rather than a computerized record.  The manual medical record is kept in the MRD itself for reference as it is important to maintain in case of legal cases. 6 All Rights Reserved © 2012 IJARCSEE
  7. 7. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012ConclusionsThe growth of computer technology has List of Abbreviationsinfluenced various medical and health related CMR - Computerized Medical Recorddisciplines but medical encounters inhealthcare setup are still documented on paper EHCR -Electronic HealthCare Recordbased medical record. The traditional paper EHR- Electronic Health Recordbased record is still used due to its familiarityto users, portability, ease of recording “soft” EHIS- Enterprise Hospital Informationor “subjective” findings, and its brows ability Systemfor non-complex patients. The health record is EMR - Electronic Medical Recordan important tool supporting quality in clinicalcare used by personnel trained in different EPR- Electronic Patient Recorddisciplines, working in different settings, on JCI- Joint Commission Internationaldifferent sites and in different languages.There are five levels of computerization of JPEG- Joint Photographic Experts GroupElectronic HealthCare Record .The study has UHID- Unique Hospital Identifydetailed the process involved incomputerization of medical recordsemphasizing on the potential benefits and its Competing Interestscontribution for improving health care The authors declares no competing interestsdelivery. The existing records that are manual Authors Contributionsare computerized and stored in JPEG ImageFormat .The Computerization of Medical The entire work has been carried as anRecord is done through 3 Tier Architecture of original research. There has been a seriousan Enterprise Hospital Information System. effort to make the research fit to the purposeApplication Server carries all the functions of and be useful for further reference.accessibility, Database Server captures data Acknowledgmentsgathered through all the departments it can be we wish to acknowledge the entire personageaccessed and retrieved. Domain Server is the who has helped us out in the study speciallysystem where all the data is saved and it alsoacts as a backup. 7 All Rights Reserved © 2012 IJARCSEE
  8. 8. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012the ones, who have helped in collecting andcontribution in data collection. 4. Richard S. Dick, Elaine B. Steen, andReferences Don E. Detme (eds.) (I991). The 1. James L. Rogers and Olga M.Haring Computer Based Patient Record, An (1979), The Impact of a Computerized Essential Technology For Patient Care, Medical Record Summary System on Washington, DC: National Academies Incidence and Length of Press Hospitalization, Medical Care, vol.17. No.6, pp. 618-625 5. Waegemann (1996) C.P. The five levels of electronic health records. MD 2. Kathryn J. Hannah (eds.)(2006), Computing. 13(3):199-203 Information Technology Solutions for Healthcare, Springer-Verlag London 6. William R. Hersh (1995), the Limited electronic medical record: problems and promises ,journal of American 3. Michael R. Ripchinski and Dwight O. society of information science , 46 Eichelberger (2008), what can (10),772-776 electronic medical records do for you? How EMR technology can affect the Processes of Clinical Care, the journal of Lancaster general hospital, Vol.3, No, 4:119-124 8 All Rights Reserved © 2012 IJARCSEE
  9. 9. ISSN: 2277 – 9043 International Journal of Advanced Research in Computer Science and Electronics Engineering Volume 1, Issue 4, June 2012Correspondence:Syed Murtuza Hussain BakshiVice Principal and Associate ProfessorAddress: Deccan School of ManagementDepartment of hospital management,Owaisi Hospital and Research Center,Hyderabad, 500058 Email: murtuzain21@gmail.comDr.Sesham Mayuri RajAddress: Deccan School of ManagementDepartment of hospital management,Owaisi Hospital and Research Center,Hyderabad, 500058 Email: drmayuri09@gmail.com 9 All Rights Reserved © 2012 IJARCSEE

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