3. What is a medical record? What is the current state of medical records?
4. Efficiency Challenges Lack of Comprehensiveness Ambiguity Lack of Accessibility Lack of Interoperability Lack of Accountability/ Confidentiality/Security
5. Improvement provided by Electronic Medical Records Immediate access to patient records. Legible, complete documentation Improved efficiencies
6. Improvement provided by Electronic Medical Records (con’t) Appropriate alerts and reminders Reduced expenses Reduced duplication of services Improved patient satisfaction
7. Desirable characteristics of electronic medical records Comprehensiveness Accessibility Interoperability Confidentiality Accountability Flexibility
From MEDIT 225 , my name is KellyHaslam along with my teammates, SoussanAhmadi and Hilary Facer. We are here to present to youA close look at fragmentation of medical recordsAnd to explain its impact on the current state of Health Care
What is a medical record?A Medical Record is a collection of documentation about a patient’s individual medical history and care which stores data related to the patient’s health by healthcare providers. It contains the patient’s demographic information, health history, lab test result, physical examination, drug prescriptions and any other diagnostics performed for a patient.What is the current state of medical records?Traditionally, medical records have been kept in a paper format. Hand written documents and notes by physicians, nurses, and laboratory staff and other general medical providers as well as patient signatures are gathered into different files. Each day, medical practices across the United States waste hundreds of hours of human resource time simply shuttling records back and forth. As technology/computers have expanded intohealthcare, medical records have started to become computerized and gradually electronic medical record are beginning to replace paper files in some healthcare settings. However, there are efficiency challenges with both electronic and paper medical records.
What are theEfficiency ChallengesFirst, Thereis a Lack of Comprehensiveness Patients’ safety; with paper records it is more likely to have errors due to mispronunciation, misunderstanding of physicians/nurses handwriting. According to “Griffin: It is estimated that the use of computers in health care could eliminate as many as two million drugs interactions and 190,000 hospitalizations each year.Same study suggests that 86% of medication errors could be removed through ordering drugs electronically. This would eliminate problems of bad handwriting, errors of reading and switching similar-appearing medication names, and too-frequent problem of misunderstanding medication pronunciations. Second, There is AmbiguityFor example, illegible hand writing and ambiguous, incompletedata, and data fragmentation can cause confusion and harm patient safety.Third, There is Lack of AccessibilityBecause health information is stored both on paper and electronically, it is scattered and disconnected. When medical records are stored in paper format, it can be accessed ONLY by one but not multiple users.Multiple volumes of paper records for long-term care patients, can become bulky over time and become inaccessible due to space and time constraints. And as the practice grows, the need for storage for these medical records also grows. Over the long term, this can create a headache for medical office management. then, There is Lack of InteroperabilityPaper medical records are difficult to integrate into other systems and to transfer between healthcare practices (from GP to Specialist).Lack of standard terms prevents exchanges between systems, and medication and prescription history may be spread across several different pharmacies. All of this can cause delay in treatment.Finally,Thereis Lack of AccountabilityPaper medical record can be cumbersome, Paper medical records are slow. They must be handled by individual staff, shuttled from room to room each day with sometimes unfortunate results. They can be lost; they can be misplaced, and are often mixed up in the day-to-day business of running a clinic or practice.
By replacing Paper Medical Records to Electronic Medical Record, there are substantial improvements in patient care. The improvements are immediate access to patient records, allowing comprehensive review of patient information at the point of care, legible, complete documentation resulting in better patient care and more accurate coding practices and improved efficiencies in treatment, payment, and other practice administration.
Other improvements are appropriate alerts and reminders resulting in improved patient care and fewer treatment errors, reduced expenses for office supplies, transcription, record retrieval, and etc, reduced duplication of services which may be offset by implementation and ongoing maintenance costs, and improved patient satisfaction.
Even though the electronic medical records significantly improve overall health care efficiency, however, there is still room for desirable enhancement.In order to conform to the guidelines of public standards and patient control, developers of medical record systems should strive to design their products with the following example characteristics. Comprehensiveness – Medical records should contain, at least, problem lists, procedures, allergies, medications, immunizations, history of visits, family medical history, test results, doctors' and nursing notes, referral and discharge summaries, patient-provider communications, and advance directives.Accessibility - The records ideally would be with the patient at all times, but alternatively they should be universally available, such as online. Patients should also be able to grant or deny research access to selected personal medical data.Interoperability - Different computerized medical systems should be able to share records. Without interoperability, even electronic medical records will remain fragmented. Medical records must be shared across multiple healthcare organizations. Confidentiality - Patients should be able to grant different access rights to different providers, based either on their role or on the particular individual.Accountability - Data and information entered into the record must be traceable by its origin. Any access history or change in a patient's record should be logged and available to the patient’s viewingAnd finally, Flexibility- Medical Record must be flexible for any expansion and improvement to the system.Although there may be additional features that can add values to electronic medical record, these are the most fundamental characteristic needed for developing electronic medical record and ultimately contributing its efficiency toward overall Health Care system.With this final thought, we conclude our presentation. We hope you enjoyed the materials. Please do not hesitate to let any of us know if you have questions. Thank you. You have a nice day.
