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Electronic Medical Records

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Computer Based Medical Records

Abstract
In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.

Computer Based Medical Records Electronic health records are taking over the paper medical records in doctors’ offices and hospitals everywhere. Electronic health records will help physicians with the continuity of care of their patients. The communication between different doctors and hospitals and also within the office is much faster and easier. Coordinating the electronic health record is much easier. The system is laid out in ways that makes it easy to use and document and also find information when needed. Finally, the accountability of the system is excellent. The electronic health record will help physician’s continue care with their patient’s in a lot of different ways. The electronic systems allows for easy access and sharing of patients health records. (Chheda, 2005) A patient could have been seen at the hospital and had tests and x-rays done and then followed up with their primary physician the following day. The physician is going to want to see the test results and patients x-rays. The office calls the hospital records manager and is able to get the results and images within minutes of making the call. This is possible by having the images in the patient’s electronic record at the hospital and sent directly over to the physician’s office via the internet. With the speed of the records being transferred the patient does not have to wait for a follow-up and the doctor has the results he needs in hand to make a diagnosis and be able to treat the patient. With the continuity of care brings us to communication. The communication between the physician and patient has become more since the electronic health record. The physician has the medical information at their fingertips which allows for more time to talk to the patient about their complaints. (O’Malley, 2010) The communication among different systems is simultaneous. The physician’s office can put in information about a patient and it can be immediately sent over to another physician or hospital. (O’Malley, 2010) Also with the electronic health record the patient or physician does not have to carry the chart up to the front for check out. The patient can go to check out and the checkout nurse has everything she needs to get the patient on their way. This saves the doctor from walking up front with the patient and allows the doctor to have more time with the next patient. The coordination of the system has allowed for physicians to have several benefits of the system. After the system has been implemented into physicians’ offices they have reported the treatment of patient’s goals and plans have been more agreed upon. (GA-HITREC, 2011) Another benefit of the electronic health record coordination is the positive patient-physician relationships that have been maintained with the easy sharing of medical information. (GA-HITREC, 2011) Also, with good coordination of the system has improved the communication between physician and patient. (GA-HITREC, 2011) The electronic health record still has to follow the guidelines of HIPAA. HIPAA is in place to keep all medical records safe and private. The HIPAA law covers electronic health records and there are security measures that are to be followed to keep these records safe. One method is to have encrypted files so when they are sent through to other offices they cannot be read. (HIPAA, 2011) Another security measure is to have a backup for the system. All the patients’ files should be backed up at least on a weekly basis to ensure that none of the information is lost. (HIPAA, 2011) Another way for accountability of the electronic health record is to have each person in the office has a key card or password to access the system. This will allow for the physician to check back and see if anyone is releasing information or making changes that are not authorized. This also allows for physicians to find out who made changes to a patients record if information is inaccurate. (HIPAA, 2011) Electronic Health Records will include the same information as the paper record. This includes basic patient information such as demographics, medical history, medications, allergies, laboratory results, radiology images, and billing information. (2006) Each individual doctor can specialize their system and what they want it to include. They can add different components to the electronic health record that are important to them and needed in their practice. (2006) Even though I am an advocate for the electronic health record there are drawbacks to the system. Each individual physician will have to determine if the drawbacks are worth the advantages of the system. One of the drawbacks to the system is privacy. Privacy will always be a big factor. Some patients may not like the idea of having their medical information easily accessible by almost anybody. (The HWN Team, 2009) Electronic health records can hinder the interpersonal aspect of health care. Physicians can now just check boxes and cross things off rather than writing out what they feel and think. This makes it less personal from the doctor. (The HWN Team, 2009) Not all electronic health records are efficient. One patients system may not be compatible with another physicians and the information may take longer to get through. (The HWN Team, 2009) Lastly, electronic health records are not 100% safe and secure. If someone knows how to break into a computer they are going to get the information off the system. Systems are not completely protected from viruses or hackers either. The physician’s office will have to stay onto of the security they have on the system to ensure these things will not happen. (The HWN Team, 2009)

References
(2006) Electronic Health Records Overview. National Institutes of Health: National Center for Research Resources. Retrieved from http://www.ncrr.nih.gov/publications/informatics/ehr.pdf
The HWN Team (2009) Electronic Medical Records: the pros and cons. Retrieved from http://healthworldnet.com/HeadsOrTails/electronic-medical-records-the-pros-and-cons/?C=6238
Chheda, Nainil C. (2005) Electronic Medical Records and Continuity of Care Records- The Utility Theory. Application of Information Technology & Economics. Retrieved from http://www.nainil.com/research/whitepapers/CCR_A_Utility_Theory.pdf
GA-HITREC (2011) Electronic Health Records: Benefits for Medical Practices. Retrieved from http://www.ga-hitrec.org/gahitrec/pdfs/Benefits&20of%20EHRs%20Fact%20Sheet.pdf
HIPAA (2011) HIPAA and Electronic Medical Records. Retrieved from http://www.hipaagives.org/articles/hipaa-and-electronic-medical-records/
O’Malley, Ann S., Cohen, Genna R., Grossman, Joy M., (2010) Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less? Health System Change, Issue 131. Retrieved from http://hschange.org/CONTENT/1125/

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