Health records in today’s modern Era

Computer technology has become a vital part of human existence. Students can easily look for a resource material in the Internet; email allows families and friends communicate in any part of the world; and money transfer is fast and easy. These are just a few of the many benefits computer technology has been offering the world. The dawn of the Internet has changed the face of the world. The word electronic is rampantly heard: electronic book (eBook), electronic business (eBusiness), electronic marketing (eMarketing), and electronic banking (eBanking), among others.

Today, many transactions can be done electronically. We just need a computer (or laptop) and an Internet connection (wired or wireless), and a lot of things can be done for a day. Computer technology has also allows us to store and to organize our files. Some computers programs were developed to provide assistance in the data management of many businesses. Even our computers at home are a great help in organizing our school stuffs like projects, researches, and reports. With files and data stored and organized in computers, retrieval of those files and data are easy.

Computer technology has found many applications in the field of medicine, from the computer-operated hospital equipment to data management; and from the state-of-the art laboratory apparatus to computerized ambulances. The continuous development in the computer technology has speed up development in the field of medicine as well. New equipment, new medicines, new processes, and new medical procedures have emerged as a result of the bloom of the computer technology. Among the many applications of computer technology in hospitals, let us focus on one and that is data management.

Safekeeping, organizing, retrieving, and inventorying are processes include in proper data management. As the term implied, data management is managing or controlling all hospital data and files, compiling, and storing them. Before, when we ask for data or files, someone would give us the hardcopy or the printout of whatever data or files we are asking. In a hospital environment, how many patients are being admitted and/or discharged everyday? Imagine how tedious it is for the personnel in the hospital’s information to look for the profile (printout) of recurring patients.

Add to the tediousness the profile of new patients. And imagine how many stocks of paper are being stored in the hospital’s storage room. These stocks of paper occupy space in the hospital, when other valuable materials could have better occupy the space. Imagine a patient whose last transaction dated five years back, how long will it be to retrieve his or her data? Thus, electronic system was developed to solve this problem of storing, organizing, and retrieving hardcopies of the patient’s information. The system was called electronic health record or EHR.

Electronic health record system is being utilized in hospitals to further improve their service to their patients and to improve the hospital’s data management. Electronic health record system allows easy access to a patient’s health record in any computer or handheld device within the hospital’s electronic network (SAGE Software 2008). Complete patient’s information, medical history, previous checkups or examinations, whose doctors were assigned, billing statements, prescribed medicines, are all accessible in the electronic health record system.

Think of the comfort electronic health record system brings to both the attending physician and the patient. Less time is consumed in locating the needed medical records compared to looking for these records in the storage area. In cases of emergencies, the electronic health record system can help the attending physicians familiarize themselves on the medical history of the patients. Electronic health record system consists of electronic forms that are filled out by the authorize hospital staff about the medical history of patients. Each form has fields of information that should be gathered from patients.

One EHR form lists the patient’s medical problems. The computer sorts these medical problems in order of importance so his or her attending physician will be guided on which medical problem should be given medical attention immediately. There is also a form for the list of medicines administered to the patients. Correct dosage and when the medicines should be administered are also recorded. Another form is for the list of the patient’s allergy information. Attending physicians will be guided as to which medicines cause allergic reaction to the patients.

Food that gives allergy to the patient is also listed here so that hospital management will determine what to give the patients. Another form is for the medical history of the patient’s family (both parents). Knowledge of diseases that occur in the family is vital in diagnosing diseases. The Start How do hospitals avail of the electronic health record system? Let us look at how the Indian Health Service prepared for their electronic health record system. For the record, the Indian Health Service has been exposed and in fact pioneered the usage of computer technology in the field of medicine.

It has an existing system on safekeeping patients’ health records even before the electronic health record system became famous. The Indian Health Service called this existing system the Resource and Patient Management System or RPMS. RPMS’s main clinical software, called the Patient Care Component was introduced in the year 1984, more than two decades ago. To keep pace with the fast-changing world, the Indian Health Service has integrates RPMS’s components to a graphical user interface to avail of the services of the latest technology on electronic health record system.

The following list shows some of the functionalities of electronic health record system: Problem list. Refer to the discussion earlier. Data retrieval. Easy and fast access to the complete patient’s information.  Order entry forms. These are for requesting medicines and for the use of the laboratory.  Complete medical history. The medical history includes both that of the patients and their family members. Reminders to monitor the current state of the patients. This way, both patients and physicians get updates on the patient’s condition. Proper documentation of vaccinations.

Keep tracks of all vaccine shots received by the patients. That also includes the dosage, the after effects, and the name of the medical practitioner that administer the shots.  Notification of medical results. Patients and medical practitioners receive fast and accurate notification about the medical results. Notifications are automatically recorded for easy retrieval. Similar to Indian Health Service, Randy Upham cited the following benefits (some) should the electronic health record will be fully functional (Upham 2004):  Easy and direct access to the patient’s medical records anytime.

Easy and fast navigation of the patients’ medical records. No medical records are lost. In manual recording, files have great risk of being misplaced and lost. Electronic recording assures the safekeeping of patients’ medical records. Less paperwork. Going electronic means doing less paperwork. Less paperwork means less physical files for safekeeping.  Medical alerts. The EHR system alerts medical practitioners on issues like medical errors and patients’ allergic reactions.  Electronic transfer of the patients’ medical records to other EHR system provider.

If a patient was admitted in another hospital, his or her medical records can be transferred easily. This way, medical practitioners in the other hospital will easily have access to the records of the patient that will help in them in diagnosing the patient. The Problems Let us look at the other side of the fence now. Acquiring the whole electronic health record system involves a lot of many and trainings for those who will be authorized to operate the system. Dr. Baron with the other authors of the online journal titled, Electronic Health Records: Just around the Corner? or over the Cliff?, identified five major issues in the implementation of the electronic health record system in a community-based medical institution.

These major issues—“financing; interoperability, standardization, and connectivity of clinical information systems; help with redesign of work flow; technical support and training; and help with change in management (Baron, R. , et. al. , 2005)—must be addressed to assure the success of the implementation of the electronic health record system. The cost of the software and hardware requirements of the electronic health record system is quite huge.

For a community-based medical institution, like that of Dr. Baron and his doctor colleagues, a financial crisis is really possible. Redesigning an office that is basically okay, again involves money issues. Knowledge on this new technology is necessary so the doctors had undergone trainings to equip themselves with the needed skills. And again, the doctors paid for their trainings. The introduction of the electronic health record system had totally changed the way these doctors manage the community-based medical institution. In the patients’ side, some were amazed, some were not.

Especially during the first few months of utilizing the electronic health record system, the months where the doctors were still familiarizing themselves with the whole new electronic process, patients had observed that doctors literally had more time with the new technology than with the patients. Randa Upham listed some of the problems or some resistances to the implementation of the electronic health record. These include the following (Upham 2004):  Resistance among clinicians. A clinician is a medical practitioner who performs clinical tasks instead of doing laboratory works.

The implementation of the electronic health record system ensures added tasks for clinicians. If information is not properly disseminated, medical practitioners resist the implementation of the EHR system.  Clinical charting in the EHR system consumes more time compared to clinical charting with the usual pen-and-paper method. Since there would be added tasks for the medical practitioners, they would prepare the old style of doing clinical charting than the electronic style. Insufficient budget. Implementation of the electronic health record system requires a lot of money. This is similar to Dr. Baron’s case in the previous paragraph.

Small hospital institutions are incapable of shouldering all the expenses. Inability to align current workflow with the standardized electronic health record system. Manual documentation and recording are different from electronic documentation and recording. The new system, EHR has a different workflow. Medical practitioners have to undergone trainings in order to learn the ways of the EHR system. The Guide SAGE Software Healthcare shares six ways on how to help hospital institutions in evaluating their software vendor for the electronic health record system. These are: 1. Conduct regular meetings with the vendor and the hospital staffs.

Discuss in the meetings any problem encountered using the electronic health record system. Make sure the answers to the queries are satisfying. And have the vendor provide clear and accurate solutions to the problems. 2. Analyze the product offerings of all vendors of the electronic health record system. Choose the vendor that has been serving medical institutions for a longer time. Choose also vendors that conduct comprehensive trainings. 3. During vendors’ product presentation, make sure to try out everything. It is advisable to make a list of the features of each vendor. Then compare this with the product offering of other vendors.

Short-list the vendors that meet the medical institution’s requirement for an electronic health record system. 4. Determine who among the vendors are willing to customize the system to agree with the medical institution’s requirement. 5. Declare a deadline. Determine who among the vendors are fast to put into operation the electronic health record system. 6. With the members of the team assigned to evaluate the electronic health record systems provided by different vendors, consider the following issues: long-term functionality, good value proposition for the amount of money allotted for the system, and conduct trainings for the employees.

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