Introduction To Electronic Medical Records
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Transcript of Introduction To Electronic Medical Records
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
Content licensed under Creative Commons Attribution-Share Alike 3.0 Unported
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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