09-02-2013, 12:41 PM
Electronic Health Record
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Abstract
Electronic health record is an electronic set of patient records that contain information on
a patient’s medical history, demographics, laboratory data, medication and other important
medical information. Paper records are bulky, retrieving them is labour-intensive and cannot be
utilized by multiple departments at the same time. Electronic Health Record data is accessed
electronically by healthcare providers. Electronic health record Improve the accuracy, efficiency,
quality of health care and data recorded. EHR maintain privacy, confidentiality and reduce
medical errors. Electronic Health Record has different forms over the years. AHR, EMR, CPR,
EPR are the some of the terms of the e-health record.
Introduction
The rapid advancement of Information Technology and the explosive growth of health
information, the Medical Institutions create Electronic Health Record (EHR) [1]. An Electronic
Health Record refers to comprehensive record of a patient health care history in digital format.
The Electronic Health Record contains all health information of a patient. Electronic Health
Record data is accessed electronically by healthcare providers.
Electronic health record Improve the accuracy, efficiency and quality of data recorded in
a health record. Enhance healthcare practitioners’ access to information enabling it to be shared
by all. EHR Improve the quality of care as a result of having health information immediately
available at all times for patient care. A paperless environment will come with the introduction of
an electronic health record and eliminate many of the problems in maintaining paper health
records.EHR maintain privacy and confidentiality, reduce medical errors and costs
There are quite benefits with EHR, especially in the areas of medical error reduction,
compliance, completeness of records, decision support, accurate billing, and even returns on
investment. The health card of a patient’s contains information about the type of treatment,
patient’s medical history, lifestyle, prescribed medication, test results, etc. the healthcare
provider , insurance companies, government agencies, other healthcare providers such as nurses,
and the medical information bureau access the patient’s records [2].
Evaluation and Earlier Literature on Electronic Health Record
Evaluation of an Electronic Health Record over the years a number of terms have been
used to describe the move from a manual/ paper record to electronically in different forms [5].
Some of the better-known terms are
Automated Health Records (AHR)
The term Automated Health Records (AHR) has been used to describe a collection of
computer-stored images of traditional health record documents. Typically, these documents are
scanned into a computer and the images are stored on memory disks. Most of the focus is in the
early 1990’s was on document scanning and storing onto a memory disks. The addressed access,
space, and control problems related to paper based records. The Automated Health Records did
not address data input/output at patient care level.
Electronic Medical Records (EMR)
The Electronic Medical Record (EMR) is same as an Automated Health Records. The
EMR has been used to describe automated systems based on document imaging or systems,
which have been developed within a medical practice/health center. These have been used
extensively by general practitioners in many developed countries and include patient
identification details, medications and prescription generation, laboratory results and in some
cases all healthcare information recorded by the doctor during each visit by the patient. In some
cases EMR include the electronic medical system within a hospital, which as well as the above
includes clinical information entered by the healthcare professional at the point of care.
Health care technology and components of EHR
An Electronic Health Record (EHR) is a medical record relating to the past, present or
future physical and mental health, condition of a patient which resides in computers which
capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary
purpose of providing health care and health-related services.
The contents of the EHR comprises basic demographic data, a record of all patient visits,
diagnostic findings including also radiology images, diagnoses and performed procedures, a
lifelong medication record, personal risk data e.g. allergies, vaccinations, and clinical referral
letters. Medical records have to kept record of all patients of inpatients, outpatients and accident
and emergency patients. Medical record system should maintain centralized system. In
centralized system, they have to maintain all details of a patient one medical record like
Admissions details, Accident and emergency records, outpatient notes, and discharge list. If the
patient’s medical record cannot be found or lost by the Electronic Health Record system,
duplicate medical records can be prepared and combined with the old records.