Electronic Medical Record, Their Importance and Why They Need to Be Properly Protected

Introduction

Protecting records from destruction is an essential activity because they provide us with evidence of legal status, ownership, accounts obtained and the responsibilities that government entities or private organizations need. These records can be either electronic or in print form, and are important as they provide information required to continue to work during disasters or to resume operations after a disaster has ended. Nowadays, growing numbers of government agencies and businesses depend on electronic records. This necessitated the care and storage by various organizations of vast volumes of electronic documents. ERM originally emerged from management of the archives. The specifications for handling documents in both paper and digital formats are identical in records management and in this context the folder is the smallest category. This refers to holding an individual record as a register, in both electronic and paper media. While electronic records save us from a lot of hassles compared to paper records but there are other factors that need to be included in their management. Also The EMR systems are designed to reliably store the data and monitor a patient's condition over time. It removes the need to track past paper medical history of a patient and helps to ensure consistency and legibility of the data. It will minimize the risk of data duplication because there is only one modifiable file, which ensures that the file is more likely to be up-to-date and reduces the risk of paperwork lost. EMRs are more efficient when collecting medical data to analyze potential patterns and long-term changes in a patient, since digital information is searchable and in a single file. The widespread use of EMRs that also promote population-based analyses of medical records.

Definition

Electronic Medical Records (EMRs) is the critical core framework to facilitate the creation of medical information, which contains information on privacy such as the identity of the patient, ID number and reports of illness. An electronic medical record (EMR) is a digital medical record that either originates from an electronic file, or is transferred to an online version from paper or hard copy. An electronic medical record provides information about the health history of a patient, such as medications, drugs, examinations, allergies, immunizations, and care plans. All healthcare providers who care for a patient can access electronic medical records and can use them to help make decisions about the patient's treatment. Often known as EHR and e-Health records. An EMR offers direct access to the history of each patient, allowing the practice to monitor patient history and classify patients due for appointments, examinations, or screenings. It may also be used to assist with diagnosis and treatment. EMRs will enhance contact between them and promote collaboration in clinical environments where there are a variety of physicians, nurses, dietitians, pharmacists, and other health-care professionals. EMRs can also enhance coordination between patients and health care providers, positively affecting clinical outcomes and patient safety. An EMR contains detailed patient information, including:

1. Contact information for patients as emergency contact.
2. Vital sign such as height, weight, and body mass index (BMI).
3. Temperature.
4. Past and future medical facility appointments.
5. Physician orders.
6. Medications.
7. Medical advancement and surgical notes.
8. Agree to release information forms.
9. Allergies.
10. Past medical appointments.

Purpose of the EMR

The medical record's primary function is to act as a archive of the patient's findings and interpretation by the clinician. The documented experiences of any clinician with a patient typically start with the history and the physical exam. The history usually includes the patient's chief complaint (i.e., chest pain, skin rash), current disease history (other specific symptoms related to the chief complaint), previous medical history, social history, family history, and device analysis (other irrelevant symptoms of the present disease). The physical test includes an inventory of physical observations, for example abdominal tenderness or an enlarged lymph node Analyzed every issue and provided a diagnosis and/or treatment plan. Typically subsequent reports by the clinician are in the form of progress notes, written for each patient visit, whether performed regularly in hospital setting or intermittently as an outpatient. Records of one clinician are interspersed with those of other clinicians. Such as consultants and colleagues, and test results (i.e., laboratory or radiographic reports) and administrative details. Such various record components are also held in different locations. All medical records of a patient are likely to be stored in a medical chart(s) where treatment is given. Only in large health facilities, where both hospital and outpatient services are given (i.e., public hospitals or university hospitals), does a patient's full medical record reside in one place and maybe not even there. A number of other ends represent the patient record. This is also used as a medium of contact between different physicians and ancillary practitioners (i.e., nurses, physical therapists, and respiratory therapists) who see the patient. Additionally, in case of lawsuits attributable to malpractice or workplace injuries, the medical record acts as legal evidence. Finally, this is often used for abstracting medical research results. The medical record has taken on new meanings in recent years. With the growth of managed care, this activity has taken on increasing significance which needs both clinically based and cost- effective clinical decisions. Another more recent area of use has been in decision support, where clinicians are reminded of the efficacy or the need for testing, or are warned of problems with potential medicines. The EMR significantly strengthens all these new uses. 

Implementations of the EMR

While there is currently no full EMR, parts of the medical record have been computerized for several years. The administrative and financial sections are the most highly computerized elements. On the clinical side, reporting of laboratory results was the most common computerized feature, typically made easier with the implementation of automated laboratory specimen equipment When more functions of information processing are computerized, increasing proportions of the record are also computerized. 'Dick and Steen' note that there are many similar characteristics of all extensive EMR's. Firstly, they all contain large dictionaries of data which define their content. Secondly, all data is marked with time and date in order to make the record a permanent chronological history of the patient’s. thirdly, the systems have the capability to flexibly show data, such as flow sheets and graphical views. finally, they have a research application tool, as well as other purposes. Several successful implementations of the EMR have been in operation for decades. COSTAR (Computer-Stored Ambulatory Record), built at Hospital in Boston, was one of the earliest outpatient care record systems. It facilitates patient identification and scheduling, clinical data storage and retrieval, and financial capabilities such as billing. This helps to effectively support doctors in the decision-making process by offering warnings to potentially troublesome conditions and daily treatment reminders. Some of these and newer technologies have grown with computer and network technology itself. Most systems were initially dumb terminals connected to mainframes or minicomputers, but have since developed into microcomputer-based networks that accept client-server architectures. Future innovations, such as voice recognition or pen-based feedback, are likely to cause these systems to develop further.

Benefits of the EMR

The EMR probably has many possible benefits. Unlike the paper record, anyone using it can theoretically access it at any time. This can be conveniently accessed from remote locations too. Such as a citywide or even countrywide facility. Data are unlikely to get lost or misplaced. It will function as a comprehensive record of an individual's experience with the health care system, with an adequate back-up plan. Additionally, new views and other summaries can be produced instantaneously with the availability of all the patient data. Finally, with the ability to integrate reminders and to help decision taking, the risk of errors and omissions will be minimized. The EMR is also likely to help the broader community, in addition to benefiting the individual patient. Medical work is likely to be improved, because researchers have better access to patient information that will improve knowledge and treatment of the disease. Screening and other preventive measures would be easier to incorporate because patients with various characteristics (i.e. gender, age, presence of other risk factors) can be detected and contacted. A effective EMR requires not only the right technologies, but also dedication from both institutions of health care and providers. Thus, the same computer system in one institution that is very successful could miserably fail in another. This that make it difficult to generalize studies of EMR systems from one organization to the next. And within an organization, as technology and the program itself change, the EMR could be continually evolving, making the findings of a study of last year's system less important. Another problem in the assessment of the EMR is precisely what constitutes 'value.' As a highly quantitative field, medicine is likely to require some numerical gain, such as decreased costs or increased quantities. But assessing customer satisfaction with anything as complicated as medical record is challenging. Furthermore, given the nature of factors that affect a patient's outcome from an encounter with the health care system, variables such as those linked to the EMR as the cause of beneficial or adverse outcomes are difficult to isolate.

Problems for the EMR

The EMR has reported a range of problems including increased provider time, device downtime, lack of quality and confidentiality risks. Research at the above mentioned institutions have shown that entry of electronic orders increases the amount of time spent by physicians entering orders. Developing means to stream line command entry is a priority now. System downtime is another issue with EMR systems, while the danger of not getting access to the right piece of information at the right time is real, system systems 'rising reliability makes this less of a problem. Many computer systems in hospitals and the applications operating on them are configured for non-stop use A more important issue with EMR systems is the lack of requirements for knowledge sharing. Although there are many guidelines for the transmission of pure data, such as diagnostic codes, test results and billing information, there is still no consensus in areas such as signs and symptoms of patients, radiation. While some equate the Unified Medical Language System of the National Library of Medicine with a detailed clinical vocabulary, its purpose is far more modest, acting as a meta- that connects words through various terminology systems. A related issue with standards is that in the form of narrative text, a significant proportion of clinical knowledge is 'locked'. While a number of systems have been effective in limited fields, the natural language processing technology (NLP) is still unable to interpret narrative text with the precision needed for applications for research and patient care.

The Future of the EMR

The use of the EMR will continue to increase with the increased opportunity to monitor and scrutinize the delivery of medical care. While this article highlighted many of its advantages, it also mentioned some of the disadvantages and impediments that need to be addressed in order for the EMR to realize its full potential. What are the challenges to successful EMR development? The program must be useful to the customer, the actual clinician who will access the data and use the findings for decision taking regarding patient care. Therefore, data entry must not be overly time-consuming or otherwise difficult, although it must be equally quick and easy to extract information out. The role of clinicians is critical for effective implementation of EMR's. The program, on the other hand, must not compromise confidentiality of patients. Fair measures must be placed in place to ensure that unauthorized audiences cannot access patient information and those that violate protection are properly disciplined. However, the protection must not be so restrictive as to hinder clinicians 'use of the device. The future clinician would definitely work extensively with machines. Not only will different health care delivery systems become more standardized, but there will also be online access to greater volumes of non-patient information, such as the medical literature. This potential clinician is likely to use a computer to enter observations and symptoms, take advantage of links that connect these decision support modules and medical literature, and interact with the patient's colleagues and others.

Conclusion

The implementation of EMR has had a major effect on the management of medical record recording, chart monitoring, retrieval, data sharing, etc. The basic tasks of the Healthcare Information Management System (HIMS) will become very simple in various operations once the medical records are in electronic form. EMRS gives multiple users simultaneous access to the data on medical records. This also helps to save the hospitals 'physical housing space which is a expensive factor in all sorts of locations. When we move towards a paperless world, HIMS professionals will need to concentrate on efficient systems that produce accurate data in a timely manner, minimize space and help manage creative records. In addition to healthcare practitioners, patients also benefit from successful EMRS in terms of better care quality, increased medication safety and less frequent testing. A good EMRS will not only collect, store and manage data efficiently, but will also allow all approved staff to access it simultaneously so that everyone can. If EMR technologies are adopted and the proper software, hardware and IT services are then placed in place, the healthcare industry will benefit greatly. It will improve the satisfaction of the patient and the results for public safety. It can lift the bottom line of the healthcare facility and bend the profit curve of increasing national healthcare costs. And at a time of declining reimbursement from Medicare, Medicaid and third-party payers, it is crucial to achieve efficiencies through EMR technology. Healthcare organizations sustainability depends on who is designing the best EHR and IT programs. Those that are not going to fail, and may need to close their operations. The longer term of healthcare will remain daunting, but changes in treatment and quality are exciting at an equal period. Long-term healthcare and thus people's ability to access healthcare depend on the healthcare industry to create a profitable venture into EMR technologie.

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