Electronic Medical Records, Research Paper Example

Introduction

Electronic medical record or EMR is a generic term for integrated, computer-based, health information systems, accessible at the point of care (Skolnik, 2010). A typical EMR will be multifunctional, including an electronic patient’s health record updated in real time by information inputted at any workstation or other interface connected to a secure network. An EMR also has information management tools to provide clinical reminders and alerts, review lab results, link with knowledge sources for healthcare decision making, and analysis of aggregate data. An EMR extends the usefulness of patient data by the application of information management tools (Skolnik, 2010). EMR systems can go far beyond the core charting. It can include systems that coordinate with laboratory, radiology, pharmacy, admission-discharge, transfer functions and tools to allow data exchange with aggregate reporting systems.

The EMR offers several advantages over paper-based systems, such as:

• Ability to write more complete notes,
• No time delay between note construction and entering the information into the medical record,
• Legible, easy-to-read in formation,
• Usually contains a link to the billing system,
• No opportunity for lost files,
• The information can be kept current without confusion or repetition that is often found in paper-based medical records,
• Prescription writing systems improve completeness of medication documentation,
• Elimination of the need to transport medical records physically from one destination to another,
• Elimination of volumes of medical records, decreasing the overall cumbersomeness of patient records, and
• Increased accessibility of the records.

EMR disadvantages

Despite the overwhelming advantages to entice physicians to convert their paper-based medical record systems to an EMR system, the EMR poses a unique consideration. There is a general concern that tampering can occur by a third party altering the medical record. Although the potential exists, the EMR and its supporting database are designed to discourage and prevent tampering with the records by a third party (Carter, 2001). Many EMR programs require two electronic signatures for every entry when completed. Any additional information or change to an entry is typically required to be documented as a separate addendum entry. Unless there is collusion between the physician and the administrator jointly to alter the record, or if the physician’s password to use the electronic signature is compromised, tampering with the EMR is very difficult. If tampering is suspected, the electronic trail is traceable and would likely require investigation by an expert in EMR technology.

Implementation of widespread electronic medical records is limited by the barriers listed below:

• Physician resistance to emerging and often unfamiliar technology,
• Start up, maintenance, and upgrade costs, and
• Patients’ records and information security.

The most important component of the medical record system is the ability to obtain a cleaner sense of the time line of patient activities (Mitchell, and Haroun.2011). The interface must be flexible enough to provide suitable customization based on an institution’s needs although flexibility and customization for some components of the system are important, other aspects of the EMR must limit variability between users. The best example of this is how a system populates fields during physician data entry. As previously mentioned, the ability to search within the system is a critical capability that affects clinical, research, and quality control capabilities (Mitchell, and Haroun.2011). This functionality can be severely crippled without standardization of terminology. For this reason, data entry within specific fields is often limited to a defined data set.

References

Carter, J.H. (2001) Electronic Medical Records: A Guide for Clinicians and Administrators. USA. A.C.P Press.

Mitchell, D,& Haroun. L. (2011). Introduction to Health Care. New York: NY.Cengage Learning:

Skolnik, N. S. (2010). Electronic Medical Records: A Practical Guide for Primary Care. New York: NY. Springer.