This document discusses electronic medical records (EMRs), including their objectives, components, history of development, advantages, and disadvantages compared to paper records. EMRs digitize patient medical charts and allow for easier storage, retrieval, and sharing of patient data. While EMRs improve efficiency and reduce errors, their implementation requires significant costs and changes to workflow. Legal and security issues also need consideration with the transition to digital health 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