Electronic Medical Record (EMR)

The electronic medical record is a digital version of all the patient’s information; such as the patient records and medical history, previous treatment and tests. It is an electronic record of health-related information that can be gathered, managed, and used by authorized clinicians and staff in one or more health care organizations it replaces the paper version and is accessible simply by typing the patient name it improves the quality of patient care and patient safety.

History

The start of computerized health records actually began in the 1950s where Peter Reichertz gave a lecture on the past, present and future of hospital information systems. This was the turning point for health system and the power where there was a recognition in computers and their ability to consume data. Though it took time for the technology to become advanced enough for officials in the department to take notice but over the decades, departments began transferring data to technological devices. Many centres for healthcare information systems began making computerised throughout the 1960s and 1970s. Today, there has been a tremendous progress in medicine system though there are numerous challenges which are still being resolved.

Advantages and Disadvantages

The electronic medical information all that information is well preserved and accessible which make it easier to as the computerised administration of the information save time make it easier to schedules the appointments for the patient and order test and treatments like x-rays and physiotherapy; the physician can access the patient information like allergies and lab results and medication, past and new results. The patient safety is the main reason for this record as it could inform the physician not to prescribe a certain treatment to avoid medication interaction or in case of emergency or the ambulance where the access to this information will avoid further complications.

Despite all the advantages there are some barriers of adaptation to the system like the low number of skilled resources for implementation and support and difficulty of inserting all the old information also there are some issues with the privacy as who can access this information and who can add or alter them.

Hospital Information System (HIS)

Background

The rising social demand for quality health care services has drawn attention to the potential of health information technology (HIT) in enhancing the efficiency of medical care. HIT has indisputable impact on administrative functions, such as the reduction of paperwork and workload of health professionals, the advance in administrative efficiencies and also the wide spreading supply of affordable care. In addition, it has become obvious that computerized health information systems can be the proper tool for impeding medical errors. HIT, particularly decision support and alerting systems, has been proposed as a producing way to increase the clinicians’ compliance with evidence based clinical guidelines therefore improving consistency and safety in patient care.

Subdivision

The system deals with issues concerning administrative, financial, medical and legal aspects of healthcare. HMN Framework (WHO) subdivides HIS into six parts the first part inputs concerns into the HIS; legislative, regulatory, financial and IT aspects. Next parts are the process parts which include indicators, data sources and data managements. Indicators include the health system, health status and determinants of health. Data resources deal with the population overall health status, based on surveys and registrations, while data management includes the process of simplification and quality of data. Last parts are the outputs; information products are the process of which data is transformed to be used for decision makes to improve health systems, and disseminations and use are where information is being enhanced by the usage of decision makers.

Examples of HIS

An example of how Hospital Information Systems have improved the quality of care have been exhibited within the NHS. In 2014 the UK Government set out a strategy for full digitisation of health records. Making them accessible to all healthcare professionals and the patient themselves. This allows more effective and personalised care to be delivered at the point of need, as doctors, nurses, paramedics and other allied healthcare professionals are able to see a patients’ entire medical history. For example, using one particular treatment over another because the patient had an adverse reaction to the first treatment. HIS are better than their paper predecessors because often records would be kept within the GP practice and Hospital. Meaning that it would be very difficult to keep them both updated, especially when there are a lot of patients, and there is the risk of losing parts of them- which could have an adverse effect on patient care. Information systems also improve cooperation between different specialities as the patient will only need to tell the “story” of their condition once. So, less time would be spent trying to working out probable diagnoses as it could be done beforehand; this frees up more time for treatment. Ultimately, HIS will save money because of the reduced need for paper and printing, allowing more investment in treatment-related equipment.

Future goals

The modern EMR system has a few drawbacks that have a direct effect on the patient, health system and society. They manifest themselves in a way that data remains unprocessed and if it has been processed it may be unanalysed if analysed not read and if read the EMR does not act upon it. In addition, there is a disease focused demand (because of the intense pressure for rapid availability for data) that cause establishment of disease-specific information systems which promote the specific disease and leaving behind the large data base that cannot be renewed. So, the main goal of the of the new EMR is making the future system more available to the patients in a way that they could get an updated data right into their email, or making a user for each person so they could be always updated and involved if there is new treatment, medication or research. Also, the data should be relevant to specific diseases but in the same system to prevent the over lapping of sources. Finally, the future system may be more beneficial to medical staff so they can follow the patient needs and treat them in the right manner because they will have all the information about the patient in one place.