The Role Of A Digitized Medical Record System In The Modern Times

Author: Elan Eisen

Given the rapid growth in the field of healthcare, medical records have been the central tool in planning the care for patients, medical research and legal protection. Manual medical records have undergone considerable transformations over time, as healthcare professionals have realized that better quality healthcare can only be provided when there is a comprehensive medical record management system at place. While many nations have embraced the computerization of the medical records for quite some time, there have been several drawbacks preventing them from getting the optimal results at the time.Development Of A Medical Records Management SystemThe medical records management system involves the use of Electronic Health Records, which document a patient’s medical history in one place. In order to develop a comprehensive record management system, there are three phases involved in the process.

  • The first phase involves surveying of the existing records with the medical centers.
  • The second phase deals with defining the systems and procedures for arranging of the records appropriately.
  • The third phase involves the integration of the electronic health records and monitoring of the system to make sure that all of the patient records are preserved in a safe and secure manner.

    Importance Of An HER

    An Electronic Health Record is a comprehensive record of a patient’s healthcare report, containing important data such as identification data, medical history, lab test results, and doctor’s notes. Such a record contains all of the important data that is crucial for administering any future care to the patient. The medical record is centered on the patient and every patient who visits a doctor will have a record existing with their medical centre, where it is preserved for future references and medical research.

    While the paper records were hard to keep record of appropriately, an EHR allows for the sure and secure preservation of the medical records. Therefore, it has emerged as the dominant method of storing medical records.

    Some of the important purposes served by an EHR include:

  • It provides a means of communication for all of the healthcare providers.
  • In order to preserve the continuity of the patient’s care, the EHR can serve as an easy reference.
  • It serves as an evidence of the care undergone at a medical centre.
  • The EHR is an informational document, helping in the review of a patient’s care.
  • In the event of litigation, an EHR can help to protect the patient, physicians and the hospital from harmful consequences.
  • An EHR can provide crucial patient care information to authorized organizations and third party payers.
  • The EHR can help to protect and ensure the security of information, confidentiality and privacy of the patient information.

    Given the large number of purposes served by the digitization of medical records, these can be helpful for many individuals and groups-patients, physicians, healthcare institutions, research teams and national health agencies as well as international health organizations. The EHR can help to address a large number of the problems arising in the medical field and provide a secure method of storing the crucial information related to healthcare institutions.

    Benefits Of An HER

    The major advantage from the digitization of the medical records is the 24x7 access to the medical records. Given that the information is available online to all authorities with access to the system, the procedure for storing and accessing of the medical records becomes considerably easier. The digital system of medical records allows for the secure storage of the information on a real-time basis, providing scope for the automation and streamlining of the clinician’s workflow.

    The EHR is also the most preferred method of data storage, given that it leads to sufficiently lower incidents of errors, and duplication of the medical records. It also allows for saving valuable time, easy accessibility, convenience, accuracy and completeness in the process. Medical centers also can reduce their cost of the records management considerably with a digitized system of storage. The clinics are able to use the EHRs in their research and development procedures.

    When implementing the electronic record management system, there are certain expectations from the procedure that healthcare centers have.

    Some of the core capabilities which should be fulfilled by an EHR include:

    • Data Related To The Health Of A Patient
    It should provide immediate access to some of the crucial patient information, such as their diagnoses, allergic reactions, lab test results, and medications. These crucial bits of information will, in turn, help to provide instant life-saving care to a patient.Management Of The ResultsThe EHR provides a platform for all of the caregivers to participate in providing healthcare to any patient, by accessing the past and present healthcare information in one place. This has the scope for augmenting the patient’s treatment and making sure they have a safe treatment procedure.Management Of The OrderCaregivers are able to enter and store various orders for the prescriptions, test results and other information in a safe computer-based system. This allows for the enhancement of the legibility in the system, reducing errors and incidents of duplication of the medical records. The overall effect is that, there is an improvement in the speed with which the orders are carried out.Support Of The DecisionThe computerized decision-support system helps to improve the compliance with the medical care centers, ensuring regular screenings and other preventative practices. One is also able to facilitate the diagnoses and treatment processes.Digitized Connection And Electronic CommunicationGiven that the system is completely digitized, there is scope for efficient, secure and easily accessible communication between the providers and patients in the system. Overtime, there is an improvement in the continuity of the care provided, increase in the timeline for the diagnoses and treatment as well as reduction in the frequency of adverse events.Support For The PatientsPatients have access to their respective medical records and they are capable of monitoring and self-testing, in order to improve the control of chronic illnesses such as diabetes.Administrative ProcessesThe EHRs have several computerized administrative tools, such as scheduling systems, which can greatly improve the efficiency of the hospitals and medical centers. This helps to provide timely service to the patients.Reporting RequirementsThe electronic storage of the data has the scope for the use of uniform data standards, which are useful for the healthcare centers to respond quickly to the state, national and private reporting requirements, including those that support the safety of patients and the surveillance of a disease.

    With the help of an EHR, there is considerable patient safety as there are lesser incidents of medical errors and more structured data capture. This affects the insurance and reimbursement in a positive manner as the data collected from patients is accurate and there are lower incidents of insurance frauds in the system. Quality of healthcare in the 21st century is changing for the better with the introduction of the electronic storage of medical records.

    However, for the acceptance of this methodology of record management, medical centers and hospitals need to undergo a change in their perspective towards the system. In the fields of security and privacy, healthcare centers need to undertake changes that would help to transition appropriately from the paper records to a digitized system of management. In order make the procedure easier and effective, the best method is to employ the services of an organization that specializes in the record management systems.

    Given that these organizations have experience with the record management procedure and as they are aware of the different innovations in this field, the procedure will be effective and allow medical centers to make the shift to a digitized system of records in a much easier manner. Once the transition has been completed appropriately, healthcare centers are then able to take advantage of the improved record management process and allow patients to gain from the improved procedure.