The idea of computerizing patients’ medical records has been in existence for quite a while. But it became popularized in the past 2 decades. Prior to this, patients’ medical records, which consists of hand-written notes, test results and typed reports, were stored in form of a paper file system. Today, paper-based medical records are used in very few healthcare systems, especially in developed countries.
The Institute of Medicine (IOM) Patient Safety Report (2003) defines Electronic Medical Records (EMR) (also known as Electronic Health Records, EHR or Electronic Patient Record, EPR or Computer-based Patient Record) as encompassing:
• The gathering of electronic health data for and about persons
• The (immediate) electronic access to population-level information by certified users
• The Provision of decision-support systems and knowledge that increases the efficiency, safety, and quality of patient care.
It is a system of electronically recording, processing, storing, and transferring a patient’s medical records. An EMR can be utilized in most healthcare delivery systems, such as physician's private practices, nursing facilities, and ambulatory, in-patient, trauma, intensive and managed care settings.
The goal of electronically-based medical records is to improve the delivery of safe, quality care focused on patients’ health. Thus, the IOM has identified 8 core healthcare delivery functions that an EMR should be capable of delivering. These core functions are:
• Health information and data
• Result management
• Order management
• Decision support
• Electronic communication and connectivity
• Patient support
• Administrative processes
Center for Medicare and medicaid services provides the stage 1, stage 2 and stage 3 for Meaningful use EMR certification. EMR reduces the prescription errors.
There are a number of benefits demonstrated in using EMR in the delivery of quality healthcare. Some of these are listed below:
• Paper-based medical records often are hard to read (due to illegible handwriting sometimes), incomplete, and fragmented. With EMR, all of these issues are well taken care of as all patients’ data are captured electronically, which are easily assessed.
• With EMR, there are decreased storage space requirements as all patient medical data are captured on the computer. This is in contrast to paper-based medical records, in which many files are stacked together in cabinets. Thus, the efficiency of healthcare delivery is enhanced with EMR.
• Also, in contrast to physically searching for paper medical records from files, with EMR, patient's medical records can be searched and located electronically within seconds, thus saving time.
• EMR also provides support for continuing medical education and research.
• More importantly, EMR would ensure that patient medical data are entered easily at the point of patient care. This would ensure that the physician can effectively save time and make fewer mistakes. This is because there are already-prepared templates for entering data which contains patient history, diagnoses, treatments, etc. With these, the physician can easily know the right type of treatment to provide.
• In addition to these, with EMR, data can be modified and updated very quickly, unlike paper-based medical records.
The importance and benefits of Electronic Medical Records cannot be overemphasized. If properly and fully implemented, therefore, especially in developing countries, it will greatly aid the improvement of quality healthcare.
Dr M Santosh kumar guptha
CCS-P, CCS , CPC, COC, CIC, CPC-P, CRC, CCC, CPCO, CANPC, CPB, CPMA, CEMC, CEDC, CIMC, CFPC, CUC, COBGC, CPCD, COSC, CPRC, CPEDC, CHONC, CENTC, CRHC, CGIC, CASCC, CGSC, CSFAC, CCVTC, RMC, RMA, CMBS, CMRS, CSCS, CSBB, FCR, FNR, FOR, CHA, CHL7, AHIMA Approved ICD-10 Trainer, AHIMA ICD-10 Ambassador, India.
CEO-Medesun Healthcare Solutions.