EMR – Healthtec Software

EMR – Healthtec Software
EMR or Electronic Medical record is a computerized legal medical record that is generated in an organization dealing in providing care such as hospitals. This is a part of a stand-alone system capable of storage, retrieval and manipulation of records.
According to a recent survey in United States, only a few physicians use the EMR system. It is to be noted here that the EMR used by them is partial. Only a fraction of physicians have a complete EMR system that requires four functions:
• Computerized order for prescriptions
• Computerized order for tests
• Reporting of test results
• Physician notes
EMR should always be kept unaltered. This can be achieved by proper authentication by the creator of the system. The creator (Physician) or the custodian of the record of the health care practice or facility is bound by legislation to be responsible for the patient’s record. These records or the physical medical records are the sole property of the medical facility that prepares it. These may include but is not limited to X-ray, CT, PET, MRI, Ultrasound etc. According to the HIPAA standards, the patient possesses every right to access the information, view the originals and obtain the original copies under the law.
According to the National and International standards, electronic signatures are legal and accepted. Whenever an EMR is used to read and write a patient’s record, it doesn’t rely only on the capabilities of the workstation. The system also depends on the type of system and health care settings. This may be possible through mobile devices with handwriting capabilities as well.
Many EMR systems monitor the medical events automatically. This is done by analyzing the patient’s data to predict, detect and prevent any adverse actions. Such a procedure would also include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other necessary and critical provider notes.
In the EMR system, privacy is a huge concern for a patient. The physician or the provider can access to the patient’s records during hospitalization, payers, providers as well as the billing data associated with them. The PHI or the Protected Health Information in United States is addressed by the HIPAA or the Health Insurance Portability and Accountability Act. This confers with local as well as International laws. There are stringent laws associated with the movement of such sensitive data including that of health care.

A few of the standards used for EMR 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 EMR system has made things simpler for both physicians and patients in today’s medical field. Please visit http://www.healthtec-software.com/emr.htm for more information.