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Electronic Medical Records

Information gathering and analysis has been central to the effective delivery of healthcare. Most of the information generated in healthcare organisations is centred around the patient and such information about individual patients are kept in confidential records known as medical records.

The information contained in these records include the patient details (such as name, sex, date of birth, occupation and address), the patient’s medical history and any other relevant history, and a complete report of each event with the patient, from signs and symptoms when first presenting, through diagnosis and investigations to treatment and outcome. Other relevant information and documentation also need to be added.


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For a long while, healthcare organisations have kept paper-based records but they have their shortcomings, some of which include

  • An increasingly mobile society means that people now change their family doctor more often and these paper records have to be physically to the new doctor’s practice.

  • It is difficult to find specific information in paper-based records, increasing the possibility of missing vital information that might be hidden within a cluster of non-relevant data.

  • Paper records are hand written and these might be difficult to read or interpret by healthcare professionals other than the author.

  • Paper records make the use of decision support systems extremely difficult especially during consultations.

Electronic Medical Records (EMRs) have been introduced to address these issues and it is now possible to store part or whole of a patient’s record on a computer.

A simple EMR software presents the user with a simple user interface where the patient’s information can be entered or viewed. The user interface communicates with a database management system (DBMS) to retrieve, store or update patients data in a computer database. EMR systems might also make use of a decision support system to provide alerts and reminders, and expert guidance during consultations.

EMRs have to adhere to same standards of privacy and confidentiality that are placed on paper-based records, more so with the passing of the Health Information Portability and Accountability Act (HIPAA) in the Unites States and the Data Protection Act in the United Kingdom.

Healthcare organisations across the world have been moving from paper based records to EMRs for a while now and in the United Kingdom the drive to implement EMRs forms one of the cornerstones of the NHS Plan and the Electronic Patient Records Development and Implementation Programme (ERDIP) has produced many products to help support this NHS initiative.

Some of the advantages of which healthcare organisations that adopt EMRs can enjoy over paper-based records are

  • EMRs can get rid of the need to duplicate patient details on new documents, as these appear on the screen by default.

  • EMRs are available 24 hours a day and are accessible instantly and simultaneously by many users, and this could be beneficial during emergency care.

  • Computer generated notes are easier to read than handwritten ones.

  • Decision support is easier to implement with EMRs.

  • Transfer of records can be done electronically between different organisations no matter the distance and time, and at almost no cost, so long as the sending and receiving systems adhere to some information exchange standard such as HL7.

  • More importantly, EMRs have the potential to reduce the cost of record management associated with paper-base records through the elimination of duplication and loss of records and loss of time associated with the difficulty of interpreting handwritten notes.

  • It is also possible to implement audit trails with EMRs, so it now possible to keep a record of those who access the records, when it was accessed and what changes were made to the records.

 

 

QUICK LINKS
International Medical Informatics Association
American Medical Informatics Association
UK Health Informatics Society
Healthcare Information and Management Systems Society


Knowledge Center
Biomedical Informatics
Bioinformatics
Health Informatics
Healthcare Technologies
Software
Hardware
Networks
Hospital Information Systems
Software Topics
Operating Systems
Database Management Systems
HL7
Electronic Medical Records
Decision Support Systems


Last Updated: 10 August 2006.



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