Regardless of the growth related to computer technology and medicine, many of the medical encounters are still being documented using paper records. Electronic medical records have a number of documented advantages, yet the use of it is still relatively sparse.
The Purpose Behind Medical Records
The main goal of medical records is to serve as a source for clinical observations and patient analysis. Any records with an interaction with a patient will usually start off with the medical history of the patient and then a physical examination. The history generally contains the patient’s main complaint such as a skin rash or chest or stomach pain as well as any other pertinent symptoms to the main complaint. The physical exam will contain a list of the physical findings like enlarged lymph nodes or abdominal tenderness. This process is then followed by assessments that will adhere to the direct problem and then a plan for a diagnosis or treatment will be put into place.
Issues Surrounding Electronic Medical Records
Various issues have been recently identified with EMR (Electronic Medical Record). Many of these problems have been related to computer down-time, lack in standards, increase in provider time and threats related to patient confidentiality. A specific amount of studies conducted have suggested that electronic-order entries increase on the time doctors spend on entering these orders. In other studies it has been suggested that residents in hospitals needed around 44 minutes extra every day when utilizing computerized entries. This has however, resulted in the development of methods to streamline these order entries.
Another real concern surrounding EMR systems would be computer down-time. This means that doctors may be faced with the threat of not being able to access the required information on a patient when it is needed. However, the increase related to computer reliability in computer systems is beginning to diminish these concerns.
A far more significant problem that is related to EMR systems is the lack-of-standards for interchanging information. Even though there are standards in place for aspects such as billing information, test results and diagnosis codes, there are no consensus in relation to the areas such as the symptoms and signs of the patient, procedure codes, test interpretations and radiology. The related issues to these standards are associated with a large amount of the clinical information that is “locked” in what is known as “narrative text.”
The last concern related to EMR systems is the issue surrounding patient confidentiality and security. However, this particular problem already exists and is independent from EMR due to the fact that much of the medical information that is abstracted from these paper records exists in the electronic repositories. A number of privacy experts have already documented threats on how this information is misused.
While there are a few that fear that EMR can exacerbate these issues, many others have agreed that the computer-based records with the right amount of security aspects in place have the potential to be far more secure than paper based medical documents.