Electronic Medical Records

Electronic Medical Records
Electronic Medical records are medical records that are generated by organizations such as hospitals that specialize in providing care. These records are legal and computerized. The records are a part of a stand-alone system that has record storage, retrieval and manipulation capabilities.
A recent survey done in the United States stated the fact that only a few physicians use the Electronic Medical Records system. Additionally, what they use is just a partial Electronic medical records system. A full records system facilitates and requires four major functions:
• Computerized order for prescriptions
• Computerized order for tests
• Reporting of test results
• Physician notes
Electronic medical records have sensitive information thus, they must be kept unaltered. A proper secured authentication method can help in protecting the sensitive data. This can be enabled by the creator/administrator of the system. The physician can be the creator or the custodian of the record system and he/she is bound by the legislation to protect the patient’s record. The medical property that prepares these records has the sole ownership of such medical records. Some of these may include X-ray, CT, PET, MRI, Ultrasound etc. The HIPAA standards state that a patient has every right to access the information (medical records), view them and obtain the originals under the law.
The National and International standards approve the legal nature of electronic signatures and accept it. Electronic media records don’t solely depend on the capabilities of the workstation itself. There are other factors involved such as the type of system and health care settings. The dependence may be associated with mobile devices that have handwriting capabilities.
Electronic media records systems automatically monitor the medical events related to a patient. This is achieved by analyzing the patient’s data that is used for detection, prediction and prevention of any adverse effects. Other things included in the procedure are discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other necessary and critical provider notes.
Privacy is a critical concern for a patient in Electronic media records. This is so, because the records of the patient can be accessed anytime by the physician or the provider. This relates to the records generated during hospitalization, payers, providers as well as the billing data related to the patient. The Protected Health Information (PHI) in the United States is addressed by the HIPAA or the Health Insurance Portability and Accountability Act. This is applicable both locally as well as internationally. The laws on record maintenance are stringent particularly those associated with sensitive data.
A few of the standards used for Electronic Medical Records system today are:-
• XML - Document format with interpretability
• HL7 - Format for interchange between different record systems and practice management
• ANSI X12 (EDI) - Transaction protocols used for transmitting virtually all the aspect of patient data. This is prominent in United States.
• CEN - CONTSYS (EN 13940), Supports continuity of care
• CEN - EHR (EN 13606), Standard for the communication of information
• CEN - HISA (EN 12967), Standard for inter-system communication in a clinical information environment.
• DICOM - Standard for communicating radiology images
The Electronic Medical Records system has provided ease to the record related processes between a patient and the medical facility. Please visit http://www.healthtec-software.com/electronic-medical-records.htm for more information.