Electronic Medical Records

1. Electronic Medical Records

2. Medical Record
• Medical Record is a chronological written
document of a patient's examination and
treatment that includes the
patient's medical history and complaints, the
physician's physical findings, the results of
diagnostic tests and procedures, and
medications and therapeutic procedures

3. Medical Records – Objectives
To review patient care, to take appropriate
clinical decisions & develop treatment plans
Provides an archival and legally acceptable
record
Provides material for researchers
Act as a source of information for heath
administrators

4. Medical Records – Objectives
To aid in hospital auditing
Easy availability of patient data
Be subject to access controls to protect patient
privacy, to avoid un-authorized/misuse

5. Purpose of patient data documentation
 As a proof of patient’s health condition
 Disease surveillance
 Disease statistics
 Formulate national health programs
 Justifying Billing
 Legal Defense
 Data for Research

6. Medical Records – Where we stand
Lacunae in maintaining medical records in
public hospitals
Non-availability of medical records for OPD
services
Non-availability of area-specific morbidity
Functional inefficiency of Integrated diseases
surveillance system

7. • Organizational:
– Information storage and retrieval
• Logistical:
– Wear and tear
– Back-ups
– Can only be at one place at a time
• Research
• Passive nature of paper- as paper itself can’t point
out mistakes during data entry
Disadvantages of paper records

8. Electronic Medical Record
• An Electronic Medical Record (EMR) is a
digital version of the traditional paper-
based medical record for an individual.
• The EMR represents a medical record within a
single facility, such as a doctor's office or a
clinic.

9. Electronic Medical Record
• An Electronic Medical Record (EMR) is a
digital version of a paper chart that contains
all of a patient's medical history from one
practice. An EMR is mostly used by providers
for diagnosis and treatment

10. Electronic Medical Records and
Patient Data
Availability, transfer and retrieval
Linkage
Storage
Data Views
Abstraction & Reporting
Data Quality and Standards
Decision Support

11. History - EMR
 Prior to 1960s, documentation was mainly a list
of diagnoses and treatments
 Larry Weed introduced the problem oriented
medical record. SOAP format (an acronym
for subjective, objective, assessment, and plan)
was born

12. Development paralleled technology
 1970s – room filling computers with very
limited capacity
• First very limited records systems appeared
• Limited terminals

13. Development paralleled technology
 1980s – PC revolution
• Large scale community based system
concept
• Master Patient Index file
• Required cooperation and joint funding
• Billing systems came into existence

14. Development paralleled technology
 1990s – Graphical interfaces
• PCs commonplace
• Local networks, internet
• Practice based electronic medical records
• Institutional home grown systems
• Integration with billing systems

15. Development paralleled technology
 2000s – modern electronic health records
• PCs in most personal offices
• Memory and storage limits go away
• Systems more robust – security, logging of
activity, faster and more complex networks.
• Integration of systems
• Young physicians have grown up with PCs

16. Components of a EMR
• Integrated view of patient data
• Clinician decision support
• Clinical order entry
• Access to knowledge resources
• Integrated communication support

17. Obstacles – Electronic
Medical Records
Technology Investment
Adoption by the user
Modification of existing practices
Understanding of legal and ethical issues
Holistic view of the service to the patient

18.  Conveying information to colleagues
 Shared record within the organization and across
sites
 Legibility
 Ease of search
 Granularity of information
 No Misfiling
 No Lost charts
 Letter templates, data extraction, automated test
results
EMR and it’s Results

19.  Justifying billing
 Automated audits
 Software suggested billing codes
 Automatic inclusion of diagnoses addressed
 Legal Defense
 More complete records
 Full audit
 Reminders – preventive care
 Reminders – diagnosis related

20. Advantages of EMRs
• Efficiency:
Retrieve patient profiles
quicker Patient access to profiles
Reduce errors
• Easy to transfer information:
Ex: In natural disasters like Hurricanes and
floodings
Ex: If practice has closed or relocated

21. • Saves money:
Cost of filing folder and paper
Cost of labour
Patients saving money
Easier billing
• Saves space
Faster work flow

22. Disadvantages of EMR
• Financial Issues:
High Initial implementation cost:
 Time and patients lost
Cost of training
Uncertain return on investment

23. •Personal Issues
 Lack of physician support for EMRs
Technical matters
Difficulty using new software
 Lack of support for technical difficulties
 Inadequate consistency of electronic records

24. • Security Issues:
Lack of medical policy specific to EMRs
Potential threats:
 “Inside attacks”
Information hungry employers
Insurance companies

25. Legal aspects of EMR
• Risk for medical malpractice claims
• Likelihood of medical errors which include
errors in CPOE, Pharmacy medication errors
• Vulnerability to fraud claims
• Breaches, theft and unauthorized access to
protected health information
• protection against undesired retrieval of
patient information

26. • Data maintenance in case of MLC and Special
category records
• Clinicians' responsibilities for reviewing the
entire computer-accessible clinical synopsis
from multiple clinicians and institutions
• Adoption of new technology and transition
from paper-based to electronic form
• EHRs may increase clinicians' legal
responsibility and accountability in terms of
technology usage, sign in/out’s

27. • User tracking can be easy since records are
maintained up-to-date
• Centralized access of health information of
population
• HIPAA act on health information protection
facilitates patients claims on breach of
information on physicians