HIBBs is a program of the Global Health Informatics Partnership

Introduction To Electronic Medical Records

Y. SINGH

NELSON R. MANDELA SCHOOL OF MEDICINEDEPARTMENT OF TELEHEALTH

SINGHY@UKZN.AC.ZA

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Learning Objectives

What a electronic medical records

Disadvantages of paper based records

Examples of electronic medical record system How to assess the benefit of a computer

based record system

Introduction

Medical chart or medical record

Comes from the idea of patient information

Why should a doctor write these notes?

Too recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, to justify interventions

Organisational: Information storage and retrieval

Logistical: Wear and tear Back-ups Can only be at one place at a time

ResearchPassive nature

Disadvantages of paper records

Electronic Medical Records

• EPR - Electronic Patient Record

• EMR - Electronic Medical Record

• CbPR - Computer-based Patient Record

• CPRS - Computer Patient Record System

• EHR – Electronic Health Record

What’s the Difference?

What is the difference between a CPR and an EMR?

Patient orientated

Comments by Clinicians

Video One and Two

Technology Intervention

Use of database technologies Information retrieval Different levels of use Structured vs unstructured Scheduled back-ups

Semi or automatic data entry Voice, handwriting recognition, direct entry via

keyboard Templates

Data communication

Technology Intervention

Security

Unwarranted fear

Strong passwords

Encryption and digital signatures

Clinical decision support systems

Cost savings

Improve quality of care

BUT ….

Problems

Technology: Infrastructure Training and expertise Perception

Human Factor May create discord

Change management

Assessing Benefits

Are all EMRs benificial?

NO Comprehensiveness of information

Duration of use and retention of data Degree of structure of data

Ubiquity of accessWorkflow

Etc etc etc etc etc etc etc etc etc etc etc …

Components of a EMR

Integrated view of patient data

Clinician decision support

Clinical order entry

Access to knowledge resources

Integrated communication support

Issues with CPR – Data entry

• Data Capture

• Data Input

• Error prevention

Issues with CPR – Data Display

Bruce Slater

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