The document provides an overview of electronic medical records (EMRs), including their key components and benefits. It discusses how EMRs work, allowing patients to create and access their own medical records electronically from anywhere. Medical information is stored digitally and can be shared securely between providers. EMRs improve care quality by facilitating access to complete patient histories and enabling features like clinical decision support, electronic ordering, and reminders for preventative care. Overall, EMRs increase efficiency, coordination, and safety of healthcare delivery.
2. INTRODUCTION TO EMR
• EMR encompasses the information and capabilities required to support
healthcare service delivery, where the information is captured in a computer-
readable form that supports interoperability and clinical decision support.
• In addition, it is likely that increasing numbers of consumers will have direct
access to EMR systems.
• An electronic health record is a representation of all a patients’ data that
would originally be found in the paper based record.
• It contains all information ranging from pathology, radiology and clinical
information that has been combined and structured in a digital form.
3. WORKING OF EMR
The working of EMR is simple and can be made clear by the following
information.
1.Create your own medical record:
• As a patient, you can create a own data base of your patient records.
• You can request to other clinics and contact to other doctors.
• Information is typed into a format such as an EMR records that contain health
care and medical information just as paper medical records
• Each user is given a unique Medical Record number (MR no.) at the time of
registration.
• The user can access their profile anywhere at anytime to know their health
details.
4. 2. Data storage
• Data is stored in computerized networks and data banks.
• Such data is typed into the computer by health information or medical
records personnel and stored in any number of medical software
systems accessed by health care providers around the globe.
• Notes and prescriptions on patient care and treatments inserted into a
patient's electronic medical record enable patients in other locations,
states or countries to access such information for enhanced care and
safety.
5. 3. Accessing Information
• You can then access medical data via information exchanges accessible to
outpatient facilities, physicians and hospitals through a dedicated and secure
network of providers in order to share information.
• Your patients are identified by codes or numbers assigned to patient profiles.
4. Web Browser Security
• Health care providers can access a patient's database or electronic medical
record by accessing health network exchanges on certain Web browsers after
entering encrypted passwords and user ID codes into the system.
• Electronic medical records enable a constant secure and confidential flow of
information between medical and health care providers that can cover and blend
a variety of specialties and disciplines.
6. OBJECTIVES
1. Enable a user to electronically record, modify, and retrieve
patient demographic data including preferred language,
gender, race, ethnicity, and date of birth.
2. Maintain the patient’s active medication list
3. Maintain an up-to-date problem list of current and active
diagnoses
4. Computerized physician order entry (CPOE) of medications
5. Capability to exchange key clinical information among
providers of care and patient-authorized entities
electronically
7. Our Features of EMR
1) Exchangeability
Multiple care providers, in different locations, can simultaneously view a patient's
medical record on their computers and get up-to-the-minute information on test
results and other doctors' recommendations. This collaboration enables care
providers to work more efficiently in determining if further consultation or testing is
required.
2) Easy adoption
Complete patient records can be accessed from any location equipped with an
Internet connection, allowing therapists to work from the clinic, home, spas and
corporate venues. Treatment can be initiated quicker and duplication of tests is
eliminated.
3) Free of cost
Our goal is to reach more people and make them aware of the importance using
Electronic medical record with which they make can access their health issues
very effectively. So, we are providing our service for free for this social cause.
8. 4) Up-to-date
Your health information is up-to-date. There is no delay as hand-written
notes wait to be transcribed. Test results and all of your medical history
are recorded directly into your EMR.
5) Reduced risk
1) EHR can provide information to improve risk management and
assessment outcomes.
2) Patient portals assist clinic owners in identifying clients that aren’t likely to
follow prescribed treatment and those inclined to self-terminate their care.
6) Improved quality
Improved legibility, accuracy and completeness. With an EMR there is
less potential for medical errors as well as improved quality and safety in
patient care.
9. 7) Reminders
1) Automatic reminders can improve disease prevention and early
diagnosis.
2) Reminders are activated when certain health maintenance tests
and/or procedures are due
8) Active decision
Standardization of data elements and information models to ensure
semantic interoperability enabling the implementation of active
decision support
9) Efficiency tool
Provides a tool for managers, executives, and auditors to measure
hospital performance based on primary source data by giving access
to atomic structured information in real time (as opposed to, for
example, scanned documents). This dramatically reduces the time
between the collection of data and the analysis of key performance
indicators and offers unparalleled richness and visibility of operational
activities from the point of care
10. Your BENEFITS
• Within the EMR, the patient’s medical data including demographic and
insurance information as well as listings of diagnosis, medications, allergies,
immunizations and other vital medical information are precisely and
succinctly organized, using standardized terminology. Results of laboratory
tests and x-rays done in the office or at the hospital can be immediately
added to the record. These results can be graphed and viewed in a number
of meaningful forms. In the near future, the results can be rapidly passed on
to the patient
• Patients benefit from improved efficiencies and service as a result of the
EMR. Prescriptions are electronically sent directly to pharmacies and are
ready to be picked up after the office visit. Marked reductions in prescription
errors and drug interactions have already been demonstrated in
southeastern Michigan from the use of this technology. Patients may also be
able to request referrals, prescriptions refills, and appointments through the
Internet from their physicians’ offices.
11. • The electronic medical record has other features that are of benefit to
patients. Automatic reminders for a variety of preventive health measures
are easily generated. These reminders can improve disease prevention
and early diagnosis. The integration of laboratory and x-ray reports with
other data in the EMR provides a more succinct and exact view of all of a
patient’s medical information. No longer will the physician have to page
through sheets of handwritten notes in a paper chart searching for
information.
• If a patient from any of the participating groups arrives in the community
hospital urgent care or emergency room, the staff physician will be able to
retrieve the patient’s list of diagnosis, allergies and medications within
moments from the health information exchange. This will reduce medical
errors potentially caused by a lack of accurate, up to date information in
the urgent care or emergency room.
12. ADDITIONAL BENEFITS:
1. Viewing
• All practices used EMR viewing capabilities, which improve chart availability,
data organization, and legibility.
• Quality benefits depended on the amount of viewable clinical data.
• The amount of initially viewable data depended on efforts to type in existing
paper-based medical record data and to electronically import data from lab,
billing, and other systems.
• As patient data accumulated over time, financial savings accrued from less
staff time spent finding, pulling, and filing charts and less physician time spent
locating information.
13. 2.Documentation and care management
• We identified a consistent relationship between greater electronic
documentation by physicians and greater quality improvement and financial
benefits.
• Although most clinicians maintained electronic problem and allergy lists,
physicians varied greatly in how they documented progress notes.
• Basic use of the EMR improved the legibility and accessibility of progress
notes and increased the availability of electronic problem and allergy lists.
More advanced use of documentation templates led to greater opportunities for
improving quality of care.
• In most practices the bulk of EMR-related financial benefits came from
reductions in medical records and transcription staff as physicians moved from
dictation to typing their own notes.
14. 3.Ordering
• Basic use of electronic ordering typically consisted of physicians’ typing in
prescription orders, responding to drug interactions and drug allergy
alerts, and printing out prescriptions.
• All but three practices we studied used electronic prescribing. In large
practices, basic ordering often also included electronic ordering of
referrals and laboratory and radiology tests.
• More advanced ordering capabilities included additional decision support,
electronic transmission of orders to pharmacies and laboratories, and
better tracking of test-order status and test results, all of which can
improve quality and decrease errors.
15. 4. Messaging
• Basic use of electronic messaging among providers improved the
availability, timeliness, and accuracy of messages and increased
completeness of documentation, thus potentially reducing “dropped balls”
and safety problems.
• Much less common was advanced messaging, which included messaging
with outside providers (to improve care coordination) and with patients (to
improve patient satisfaction and, potentially, patient self-care and
compliance).
5. Analysis and reporting
• Few practices initially used physician performance monitoring and
feedback capabilities to improve quality and efficiency.
• Over time, some practices especially larger ones used reporting
capabilities more widely.
16. 6.Patient-directed functionality
• Most practices had limited or nonexistent practice Web sites for
patients.
• A few large-practice Web sites enabled patients to schedule visits, send
secure e-mail messages to providers, receive e-mail reminders, order
medications, access their charts, and obtain more individualized
educational patient care information—all of which have the potential to
improve quality.
7.Billing
• Increased integration between billing and EMR software, combined with
electronic documentation, can yield financial benefits through more
complete capture of services provided, more defensible Medicare
coding at higher coding levels, and reductions in data-entry staff
17. Your Benefits At a GLANCE..!!
• Increased Access and Efficiency
• Affordable and easy to adopt
• Feature rich EMR platform
• Enhance quality of care
• Improved Documentation
• Increased Resources
• Quality Assurance
• Eliminates Costs
• Reduced risk