Scientific and social changes of the 21st century have brought a radical change in the Health care delivery system with excellent technological innovations. One such innovation is the Electronic Medical Record System. An electronic medical record (EMR) is a medical record in digital format.The health care sector is accountable today with an alarming rise in medical litigations.This legal accountability of the health care system has given rise to a number of documents that have to be recorded ,preserved and made available to the patients on demand.
The documentation includes, 1.Diagnosis and Treatment Report which very Health Care delivery center today provides to the patient on the details of the diagnosis of the disease with follow up instructions, the Medicine information and the allergy reactions that could follow; dietary restrictions, dos and don’ts, restrictions and exercises prescribed. They take an acknowledgement either from the patient or an authorized person after receiving the report.
This documentation serves a key purpose in medical practice.2.The Health Record which is the proper documentation of records of all treatments and medications, as well as a record of a patient’s reactions and behavior. The health record is the written and legal evidence of treatment. This reflects only facts and not the judgment of the doctor. Careful and accurate documentation is vital for patient welfare and that of the doctor.
Documentation includes, medication administered, treatments done with date & time, factual, objective and complete data, with no blank spaces left in charting, on flow sheets or on check lists, calls made to health care team, client’s response, signature of the nurse in every entry and consent for treatment. A private hospital in
Milan, Italy, has been asked to handover for police verification of the medical records of at least twenty one cases who had heart valve surgery, following complaints that the surgeon replaced heart valves even in patients who did not need them replaced.3. Informed Consent, which is a document, recorded before any terminally ill person receives his chemotherapy or an invasive procedure. The patient or his/her health attorney should give a well-documented informed consent before such procedures.
Informed consent means that tests, treatments and medications have been explained to the person, as well as outcomes, possible complications and alternative procedures. Any medical hospital can be pushed into a center of a litigation storm after allegations without informed consent.4.Medical Billing and Insurance, which are part of the health care system in USA.
Electronic medical record keeping facilitates access of patient data by physicians at any given location ,accurate claims processing by insurance companies , building automated checks for drug and allergy interactions,clinical notes and laboratory reports.The term electronic medical record can be expanded to include systems which keep track of other relevant medical information.
Five levels of an Electronic HealthCare Record (EHCR) keeping can be classified as follows;
1.The Automated Medical Record ,which is a paper-based record with some computer-generated documents. 2.The Computerized Medical Record (CMR), which makes the documents of level 1 electronically available. 3.The Electronic Medical Record (EMR) which restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems.
4.The Electronic Patient Record (EPR) which is a patient-centered record with information from multiple institutions.5.The Electronic Health Record (EHR) adds general health-related information to the EPR that is not necessarily related to a disease. The development of standards for EMR interoperability is vital because of the fact that without interoperable EMRs, practicing physicians, pharmacies and health care institutions cannot share patient information, which is necessary for timely patient-centered care.
There are many standards relating to specific operation of EMRs in the USA and across the globe. These include “ASTM International continuity of care record ” in which patient health summary is based upon XML; “ANS1 X12”,which is a set of protocols used for transmitting any data including billing information; “CEN”,which is the European Standard for EMR; “DICOM”,A popular standard in radiology record keeping and “HL7” which is commonly used in clinical document architecture applications.
There are many software programs specially developed for electronic record keeping. This includes ‘Doctors partner’, an advanced Electronic Medical Records (EMR) System with Integrated Appointment Scheduling Billing, Prescription Writer, Transcription Module, Document Management and Workflow Management built to meet HIPAA standards. ‘Practice Partner Patient Records’ is an award winning electronic medical records (EMR) system, allowing practices to store and retrieve patient charts electronically. There are innumerable such branded medical record softwares available today (Ringold et.al.,2000)
The American Medical Association and 13 other medical groups representing 500,000 physicians have signaled their intention to go electronic with the AMA formed Physicians’ “Electronic Health Record Coalition” to recommend affordable, standards-based technology to their constituents. President Bush has also promoted a nationwide computerized medical records system in a recent visit to a children’s hospital at Vanderbilt University.
The National Academy of Sciences report states that the health care industry spent between $10 and $15 billion on information technology in 1996. RED medic Inc., a California based firm have introduced a cheap online medical record service with an annual membership of about $35.
The company Web site will collect, store and access everything ever wanted by health-care professionals to know about a patient’s medications, allergies, immunizations, conditions, doctors, emergency contacts and insurance providers. The system will store and transmit more complex information such as advance directives, EKGs and other essential medical documents and diagnostic imaging techniques. This health information service is capable of delivering information to any doctor or hospital, anytime, within the United States.
Although the issue of the privacy of patient records has received due attention in the last two years with arguments that Electronic medical records presents new threats to the privacy of patient-identifiable medical records, The Health Insurance Portability and Accountability Act of 1996 paved ways to protect the privacy of medical records Thus, any violation on these lines will be violation of the basic law.
Under data protection legislation and the law in USA, the responsibilty for patient records in any form including films and tracings from diagnostic imaging procedures such as x-ray, CT, PET, MRI, ultrasound, etc. lies always on the creator and custodian of the record, who is usually a health care practice or facility and the patient owns the information within the record and has a right to view the originals, and to obtain copies under law. Thus, electronic medical record system is a technologically viable cost effective system that has to be utilized by the health care sector governed by legal and ethical principles.
EMRs can serve a great purpose by making the patient data available to any authorized physician or patient anywhere and anytime towards more transparent health care when monitored effectively.
- Hallvard Lærum, MD, Tom H. Karlsen, MD, and Arild Faxvaag, MD, PhD. “Effects of scanning and eliminating paper based medical records on hospital physician’s clinical work practice”.. Journal of the American Medical Informatics Association 10: 588-595. 2003.
- Medical Board of California: Medical Records – Frequently Asked Questions.
- Ringold, JP Santell, and PJ Schneider. “ASHP national survey of pharmacy practice in acute care settings: dispensing and administration–1999”. American Journal of Health-System Pharmacy 57 (19): 1759-75. 2000.
- US Code of Federal Regulations, “of Individually Identifiable Health Information” Title 45, Volume 1,October 1, 2005.