The document discusses electronic health records (EHR) and electronic medical records (EMR), highlighting their importance in patient care and the challenges they face, including issues of interoperability, privacy, and technology infrastructure. It emphasizes the need for standard terminologies and controlled vocabularies to improve communication and data exchange among healthcare systems. Additionally, it outlines retention periods for medical records in the Philippines and various challenges affecting both physical and electronic record-keeping.

1. ELECTRONIC
HEALTH
RECORDS…..ISSUES
AND CHALLENGES

2. THE MEDICAL RECORD
The medical record is an important document that must contain
sufficient data to identify the patient, support the diagnosis or
reason for attendance at the health care facility, justify the
treatment and accurately document the results of that treatment”
The main purpose of the medical record is:
• to record the facts about a patient's health with emphasis on
events affecting the patient during the current admission or
attendance at the health care facility, and for the continuing care
of the patient when they require health care in the future.

3. ELECTRONIC HEALTH RECORDS DEFINED
What is Electronic Health Records (EHR):
: contains all personal health information belonging to an
individual, entered and accessed electronically by healthcare
providers which extends beyond acute in-patient encounters
including all ambulatory care settings at which a patient receives
care.
: is an official health record for an individual that is shared among
multiple facilities and agencies. There are government incentives in
many countries to standardize EHRs and ensure that every citizen
has one.

4. ELECTRONIC MEDICAL RECORDS
What is Electronic Medical Records (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. It is a computer
system that records patient’s demographics and medical data for
long-term storage and analysis.

5. RETENTION PERIOD FOR MEDICAL
RECORDS IN THE PHILIPPINES
Retention Period for Patient Records as stated in DOH Circular No.
70, S. 1996.
• 15 years retention period – in patient records
• 10 years retention period – out patient records from date of last
visit

6. ISSUES AND CHALLENGES IN MEDICAL
RECORDS
1. Legibility of entries
2. Lack of standard terminologies (ICD 10 terminologies
for Diagnosis and CPT procedure codes terminologies)
3. Incomplete documentation
4. Manual consolidation of reports
5. Filing space for patient records
6. Access to Health Records anytime, anywhere in a secured
manner

7. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
1. INTEROPERABILITY OF SYSTEMS/STANDARDS
INTEROPERABILITY is defined as the ability of two or more systems or
components to exchange information and use the information that has been
exchanged.
• Information communication is a key component in any system. Effective
communication requires that information senders and receivers share a
common “reference framework” that enables all interactions to be
understood. Standards provides this common framework, promoting
uniformity in the definition and identification of health system components,
whether objects, diagnosis, people and intervention.
• Syntactic or Functional – structure of a communication
• Semantics – holds the meaning of a communication

8. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
1. INTEROPERABILITY OF SYSTEMS
A Controlled Vocabulary is a key component in achieving the interoperability of health
information system, this does not only facilitate system interoperability but also enable statistical
and epidemiological analysis, reports for computer assisted decision-making, planning of care
and follow-up strategies.
Importance of Controlled Vocabularies
• Standardizing free text or structured contents of the medical record
• Representing clinical observations and evaluations
• Coding tests and results
• Identifying drugs
• Interchanging clinical data in real time
• Representing syntactic and semantic aspects of medical concepts
• Recovering and analyzing data, and supporting the decision-making process

9. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
1. INTEROPERABILITY OF SYSTEMS
Examples of Controlled Vocabularies:
SNOMED CT
LOINC
DRG
ICD 10
CPT
NDC & Rx Norm

10. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
2. PRIVACY AND CONFIDENTIALITY OF INFORMATION
• Assurance of the confidentiality and privacy of data, laws that must
cover the EHR.
• Data Privacy Act of 2012 or Republic Act 10173
3. Implementation guidelines in Electronic Health Records
• Philippine Health Information Exchange
• Administrative Orders and Circulars from Regulatory Agencies
• E-Commerce Law or Republic Act 8792 – is healthcare included in
the digital information processing included?

11. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
4. Technology Infrastructure
• Internet connectivity stability
• Redundancy of Storage must be defined
• Disaster Recovery Plan
• Systems Security
5. Risk Management
6. Change Management