Background of Medical Records
Back in the date, when there was not much tech development, hospital and clinic staff were supposed to collect patient data from them on each visit and record it manually in a folder and that too was done exclusively on papers. It required a significant amount of time, energy, and patience from collecting information to writing it down and keeping it safe for years. It was in the 1960s, Dr. Lawrence L. Weed, a physician understood the pains of clinical staff and introduced this new concept of electronic medical records. His concept was later experimented and over a period of time with the advancement in technology finally, in the 1990s a proper EMR system was created.
What is an Electronic Medical Record (EMR)?
Basically, an EMR is the advanced adaptation of data gathered in a physician’s paper record or document. It contains everything from clinical history, prescriptions, diagnosis to labs, allergies, past medical history, and treating physician’s notes. Electronic clinical records record this fundamental clinical information on web-based software. Plainly described, it’s a digital replica of patients’ medical information as recorded in health practitioner’s paper file. So, basically, it’s the complete paperwork of medical records that are digitalized and saved on an electronic medium for easy access. There is this concept called “GO PAPERLESS”. Electronic Medical Record (EMR) is an example of going paperless.
Difference Between an EMR (Electronic Medical Record) & an EHR (Electronic Health Record)
Very often, the two terms are confused and used in place of the other which is entirely wrong. Because both are not interchangeable and serve different purposes when it comes to the needs of a physician. At one end, Electronic Medical Records patient’s medical data in a particular health facility. This data is not accessible to another hospital or health service provider. EHR, however, covers the broader health & medical spectrum of a patient which they can carry with them in any clinical setting.
Whether to choose EMR or an EHR for your practice setting, entirely depends upon the functions of your setup.
General Features of an EMR
An EMR system provides physicians access to medical records like never before. An electronic medical record software generally offers the following features;
- Document scanning
- Clinical Charting
- E-prescriptions (electronic prescriptions)
- Medication tracking including past medications
- Patient referrals
- Appointment checkers and reminders
- Lab orders and reports
- Immunization history
- Customer support
Types of EMR
It is extremely vital to select the best type of EMR for a medical setup because this can make or break a practice.
1. Cloud Based EMR
A secured data center is the prime choice when it comes to web-based hosting. To get to it, all you need is a cell phone, tablet, or PC with an internet browser. No need for additional software to log in to a cloud-based system. You can access your system from anywhere around the world if it’s a cloud-based software.
Cloud-based frameworks have fewer equipment necessities. There’s no compelling reason to buy or keep a worker or extra equipment—any workstation with admittance to the web will do.
There’s less worry for calamity recuperation or information reinforcement, and you don’t need to stress as a lot over actual security.
One downside is that since you don’t control the framework through your IT division, therefore it might result in unwanted circumstances such as; internet outage, line failure, and so on, which could make it difficult to get to billing and patients charts.
2. Server-Based EMR
This is like a rose with thorns. It does come up with higher up-front costs as compared to cloud-based EMR systems but it brings you a lot more on-site advantages. You need to think about the long-haul venture, and how your training or office will develop prior to putting resources into this sort of framework, however, it enjoys some upper hands over a cloud-based EMR framework.
A practitioner or a practice in agreement gets software with licenses and can install it on as many systems as required. This system is accessible through remote connections. One noteworthy feature of server-based EMR is the increased speed and performance on onsite located systems.
Benefits of Electronic Medical Records (EMR)
The biggest advantage of an EMR is automated documentation, storage, and retrieval of patients’ medical records which becomes a click away.
1. Paperless Record Keeping
Going paperless is the idea behind EMR. One of the noteworthy advantages of EMR is paperless practice.
2. Reduced Office Cost
No paper means no additional cost on printing, writing prescriptions, and keeping hard copies of lab reports and medical history. This does cut off an additional cost a practice has to face.
3. Easy Medical Record Documentation and Retrieval
There is no more document pulling from piles of papers. Your patient record is just a click away. EMR provides you with accurate, error-free, complete, and up-to-date information about patients.
4. Improved Communication and Care Coordination
Quick access to patient records at the point of care implies more coordinated, efficient, and improved care rendered to patients.
5. Efficient Treatment and Improved Patient Care
When the system is in place and running smoothly it results in timely delivery of patient’s data as and when required. This results in efficient treatment and improved patient care.
6. Reduced Medical Record Errors
Sharing electronic information reduces the errors of medical records being replaced, missing, and misinterpreted.
Conclusion – Improved Quality of Health Care Is Possible Through EMR
According to a report, EMR has changed the game of health care in developed countries. Many countries have adopted EMR systems to keep records of their patients at different medical care units after USA, UK, Australia, Norway, and a few others. Pakistan however, needs to bring drastic changes to the overall health care system to provide state of art medical services to its people. Introducing EMR and EHR systems to Pakistani hospitals should be made an integral part of the digitization program. Only when the systems are fixed, point of care will be improved.