Several weaknesses of paper-based medical records have been identified, such as illegible handwriting, ambiguous and incomplete data, data fragmentation, and poor availability. 1 In addition, paper records often become bulky with time, which leads to lack of overview. Because paper records still represent the usual medium for collecting and recording patient data, these weaknesses could impede the continuity and quality of care.
Allow for all medical offices to send, receive, and share data & resources throughout the network Upgrade all hardware/software to ensure network operability Allow scalability for growth of and on the network Merge all five medical offices without slowing down current service at any location Provide physical security in addition to complying with the current HIPPA laws Allow for a redundant connection Implement a plan for disaster recovery, backups, and how security will exist and be maintained
Medical institutions in america still would rather use paper to gather information from their patients and also to record surgical procedures, observations, and prescriptions. Some practitioners and physicians find accessing digital records somewhat complicated than obtaining a notepad and a pen. In america, medical records are kept for seven years; for now, they can go on and dispose them. The thing that makes manual keeping of records very exhausting may be the mere undeniable fact that every day, a large number of new records are being stored in hospitals.
It will be very complicated to sort medical records of all patients that keep increasing every minute. This complexity often arises to errors that will greatly get a new daily happenings in hospitals, clinics, and all sorts of other healthcare institutions. Aside from being time-consuming, collating records can be hard if you have no main paperback that may contain all information. Electronic medical records eliminate these complaints. With electronic permanent medical record, physicians and dieticians can easily access the required information they need from your patient to proceed with all the treatment.
Physicians can make usage of electronic tablets to check the public record information, laboratory tests results, previous medications taken, surgery and other treatments records, and present health. Instead of scanning from your thick file of documents, doctors can observe all the said information in a single click. Electronic medical records can be accessed in a health institution which uses exactly the same program. This greatly reduces the price of faxing, mailing, and transporting medical documents from different institutions.
If someone is used in another hospital for additional treatment, his information can be easily obtainable towards the hospital that may take his case. An additional of experiencing electronic patient facts are accuracy. Often, transcriptionists fight to view the writings of physicians; leading to errors. Digital records provides all of them with standard text format that’s absolutely readable. It also has security encryptions that will safeguard patients’ information.
There were numerous cases of lost medical records and documents in hospitals employing papers and storing them on big file cabinets that are a lot of the time- unattended. Nevertheless, electronic medical records may need huge investment from entities and organizations with these. The entire system will need a staff of technical associates that may keep up with the resources and information. It would even be real hard for physicians to gain access to information in the event the method is down or there were technical issues in computers.
Aside from all of these, privacy issues and legality are or worry also. Critics of this technology argue the possible proliferation of confidential information. Another thing is that the networking features of electronic medical records can’t be utilized whenever a certain hospital or doctor will not use the same program so there’s still need to transport records manually. Medical electronic records have flaws being straightened out. There are stuff that need improvement. Still, electronic digital information can be very effective if highly developed and recognized.
M. C. Kinnon is the author of The Digital Patient. His book looks at and explains the medical information revolution; how your doctor is using your digital medical information to better manage your health. As well as how you can take control of your medical information. For more information of his work, visit http://thedigitalpatient. com/website/ Abstract Objective: It is not automatically given that the paper-based medical record can be eliminated after the introduction of an electronic medical record (EMR) in a hospital.
Many keep and update the paper-based counterpart, and this limits the use of the EMR system. The authors have evaluated the physicians’ clinical work practices and attitudes toward a system in a hospital that has eliminated the paper-based counterpart using scanning technology. Design: Combined open-ended interviews (8 physicians) and cross-sectional survey (70 physicians) were conducted and compared with reference data from a previous national survey (69 physicians from six hospitals). The hospitals in the reference group were using the same EMR system without the scanning module.
Measurements: The questionnaire (English translation available as an online data supplement at ) covered frequency of use of the EMR system for 19 defined tasks, ease of performing them, and user satisfaction. The interviews were open-ended. Results: The physicians routinely used the system for nine of 11 tasks regarding retrieval of patient data, which the majority of the physicians found more easily performed than before. However, 22% to 25% of the physicians found retrieval of patient data more difficult, particularly among internists (33%).
Overall, the physicians were equally satisfied with the part of the system handling the regular electronic data as that of the physicians in the reference group. They were, however, much less satisfied with the use of scanned document images than that of regular electronic data, using the former less frequently than the latter. Conclusion: Scanning and elimination of the paper-based medical record is feasible, but the scanned document images should be considered an intermediate stage toward fully electronic medical records.
To our knowledge, this is the first assessment from a hospital in the process of completing such a scanning project. The electronic medical record (EMR) is considered a prerequisite for the efficient storage, distribution, and use of patient data in hospitals. 1 The development and implementation of EMR systems that have the capability of storing and presenting all the information contained in a typical paper-based medical record have, however, proven to be complex tasks. 2,3,4,5 In Norway, systems with the ability of storing a proportion of the information in the paper-based medical record are implemented in most hospitals. Until recently, Norwegian legislation has made it necessary to maintain the paper-based medical records, resulting in a combined electronic and paper-based medical record best described as a hybrid ( ). In this situation, the EMR systems are of limited value to physicians. 6 Figure 1. Diagram of the medical records in most hospitals (left) and in Aust-Agder Hospital (right). In the former, the paper-based medical record dominates, being the only complete record. In the latter, there is a complex mix of fully electronic medical records …
A revised legislation, enacted in January 2001, defines criteria for how the patient data can be stored solely in an electronic format. However, to obtain a complete record, several paper-based sources of patient data must be converted to a digital format without loss of medical or legal information. This includes the paper-based medical record as well as paper documents that have been created by hand or that stem from diagnostic devices or information systems not integrated with the EMR system. In practice, it means that a complete EMR system must support scanning and storage of documents as images.
Having two complete copies of a medical record is superfluous, and the next logical step is an elimination of the paper-based medical record. Since no alternative system will be available to the physician in case of failure of the computer system, this can be considered a strategy of no return. Such a radical change in work methods carries a risk of full refusal by the clinical staff, as has been reported in previous studies. 7,8 These aspects probably discourage hospitals from taking this next step toward computerization.
Although scanning of paper-based medical records in hospitals has been described by others,9,10 the effects of eliminating them are not known. In this report, we have evaluated the effects of scanning and elimination by studying the physicians’ reported performance of clinical work tasks and their attitudes toward the system. The findings were compared with that of other hospitals that are using the same system but are not scanning or eliminating the paper-based medical records. To assess these variables, we have used questionnaires, group discussions, and interviews.
Go to: Methods Brief Description of the Hospital and the EMR System Aust-Agder Hospital is a 410-bed community hospital serving a population of 102,000 in Aust-Agder County, southern Norway, caring for 18,600 inpatients and 74,000 outpatients per year (1998). The patients are admitted by primary care physicians external to the hospital and followed up by the hospital physicians. The hospital is comprised of departments for psychiatry; general surgery; internal medicine; orthopedics; gynecology; ear, nose, and throat; and ophthalmology.
Well funded, and with a strong commitment by the hospital administration, the hospital staff began implementation of DIPS 2000, a commercially available combined EMR and hospital administrative system () in March 2000. In April 2001, all except the psychiatric department started to scan documents; hence, all new patient data were channeled into the EMR system in these departments. To handle the transition to EMR, a separate project organization had been recruited from the hospital staff. The project organization provided regular class-type training for the users and a network of super users (the most experienced users) among the ward staff.
The system was available in 1,100 terminals throughout the hospital, except for the inpatients’ rooms. The patient data in the EMR are stored either as searchable text and numbers or as document images. The former, called regular electronic data, essentially consist of the chronologic, text-based medical record integrated with laboratory data in numerical form and textual radiology reports ( ). The latter are divided by structure into two categories, as follows: upon admittance or consultation, the documents in the old paper-based medical records are scanned into the system as digital images in TIFF format.
Each image contains all the sheets of one main section of the paper-based record and, hence, corresponds to a whole document group (groups A-J in ). These images are called scanned multiple documents. Searching in them is essentially done by reading the contents, aided by the dates appearing on the documents ( ). Upon patient discharge, various paper sheets accumulated during the stay (e. g. , the medical treatment form, printouts from diagnostic devices) are scanned, dated, and labeled by document type singularly ( ).
The resulting images are called scanned single documents. Searching in them is assisted by their date labels and the hierarchy of document types. This makes it easier to locate specific information in the scanned single documents than in the scanned multiple documents. In summary, the patient data are stored as regular electronic data, scanned multiple documents, and scanned single documents. They all appear in the hierarchical list in the “medical record explorer” window ( ), but are treated separately in this report because of their difference in st