Technology
Healthcare Information System: Electronic Medical Records (EMR)
Abstract
The health information system encompasses collective number technology-based infrastructures that aid the healthcare sector in improving the quality of care provided to the people. EMR or the electronic medical records is an example of a system implemented to process of gathering and utilizing patient’s health information to facilitate care in the most efficient way. EMR allow clinicians to create patient’s chart electronically and easily access lab and other test results for accurate diagnosis of the patient’s condition. The EMR is made up of five components namely the progress note entry, data module system, patient call log, prescription management system, and a backup system.
Overview of EMR
Healthcare information systems have changed the way care is being delivered. The advent of technological innovation led to the migration of health information into electronic data such as the EMR or the electronic medical records. Also referred to as electronic record of health information of individuals, which can be managed, gathered, and created by clinicians and staff within the healthcare organization (healthit.ahrq.gov, n.d.). The utilization of he EMR system significantly improves the delivery and quality of care as the workflow can be facilitated in real time because of the immediate availability of the information pertaining to the patient’s health. Recognizing the role of EMR in the healthcare environment constitutes several benefits including ease of access to patient’s information by the physician to accurately diagnose, interpret lab results, determine allergies, and medication history (Glandon et al., 2008). In addition, EMR also provides the healthcare organization particularly the care providers with a historical view of the patient’s test results, which the decision support system can analyze, to prevent potential drug interactions and to ultimately improve the level of compliance to care best practices (healthit.ahrq.gov, n.d.).
EMR is often mistaken for EHR, but the two systems are different in terms of function, components, and level of information contained for every patient. While the EHR contains a more comprehensive data on the patient’s health and medical information that goes beyond a single provider’s office, the EMR on the other hand contains only the standard data gathered and created within a single health organization (healthit.gov, 2014). For example, the EHR system was designed to collect information about the patient’s medical history from all the providers involved in providing care and the information is being shared across different health organizations. On the contrary, the EMR can be considered as the digital version of the paper chart created by a single provider, which means the information created in the EMR can be utilized within the confines of the health organization that created it. When the patient decided to change provider, the EMR data created by the care physician will be added to the patient’s general records together with other data from the other providers, thus creating the EHR, which will be forwarded by the old provider to the new provider. The EMR system is consist of five fundamental components and each one performs a specific function that contributes to its overall purpose (Glandon et al., 2008).
Progress Note Entry
Medical providers use EMR in taking notes about the patient’s state of health including symptoms and appearance through a note entry tool similar to writing notes on the patient’s chart on a sheet of paper (Fowles et al., 2008). There are EMRs that also allow the patient to input their symptoms prior to the physician’s visit in order to inform the doctor ahead of time. The purpose of this component is to gather as munch information about the patient’s state of health and the progress that the clinician had created in terms of diagnosis and treatment (Garets and Davis, 2005). The progress note entry is measured for its efficiency and accuracy using risk reduction method encompassing the practice of printing out the progress notes periodically and evaluate the information captured in the progress from the perspective of an expert witness or an auditor. This will also ensure the consistency and accuracy of the collected information.
Data Module Input System
The data module input system enables the care provider to round out the progress notes including the discussion with the patient and opinions of peer physicians about the patient’s condition into a comprehensive data. In addition, the module also allow the physician to upload the electronic copies of the documents and images from the test results in order to pull up data from tests such as CT scans, ECGs, and so on (Fowle et al., 2008). The purpose of the data module input system is to provide the physician with a 360-degree view of the patient’s overall condition. The risk reduction measure being used to determine efficiency of the EMR system suggests that measuring the efficiency of the data module input system by periodically reviewing the workflow of the existing modules to determine missing information, fragmentation, and format inconsistencies, which could compromise the quality of data that physicians pull up from the system (Health Information Technology, 2013).
Patient Call Log
The conversations between the patient and the physician are also considered as a vital piece of information that EMR also aims to capture in the system. The patient call log documents all the important phone calls between the physician and the patient in order to be pulled up for future auditing. The IT department on the other hand adds another feature of the call log system in web-based interface in order to capture patient complaints. The purpose of this component is to ensure that information regarding the patient’s health and the exchange between the physician and the patient were captured by the EMR to be used for future reference or whenever the circumstances warrant it (Bowman and Smith, 2010). The approach used in measuring efficiency of the patient call log is through a systematic audit by randomly selecting recordings of the conversation by an auditor and examine the exchange for any inconsistency of errors in the information relayed by the physician over the phone.
Prescription Management System
Prescription management system is a very critical component of the EMR because it takes several considerations about the patient’s state of health when recommending medication in part because of any persisting patient’s allergies to specific medication or active ingredient. It is important for the care providers to indicate the patient’s allergic reaction to medication to prevent any negative implications of recommending new medications. In addition, the purpose of the prescription management system is to automate the process of refilling the medication by sending the prescription to directly to the pharmacy for refills, which the patient can pick up afterwards (Keshavjee et al., 2013). The way to measure the effectiveness of the prescription management system is more complicated than the other components because it will require assurance of network stability and information security considering that the prescription information is being forwarded externally.
Backup System
The large quantities of information gathered in the day-t0-day operations of the EMR require both a virtual and non-virtual system where the data can be stored safely and securely. The patient’s information is protected by legal statute where an inappropriate use of such is considered a criminal offense. The purpose of a back-up system is to secure the availability of the information in any event of disasters of system failures. Recovery plans are crucial for EMR because it the unavailability of the patient’s information is likely to result to delays in providing care services. In addition, the absence of available data about the patient’s health poses a risk of medical errors. The backup is being kept offsite to keep it protected from intrusion and allowing it to be accessed when necessary. Measuring the effectiveness and efficiency of the backup can be done through periodic auditing and system integrity check to ensure the strength of the security protocols implemented in the backup system.
References
Bowman, B., & Smith, S. (2010). Primary care direct connect: How the marriage of call center technology and the EMR brought dramatic results—A service quality improvement study. Perm J. 2010 Summer, 14(2), 18–24. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912077/
Fowles, J., Kind, E., Awwad, S., Weiner, J., & Chan, K. (2008). Performance measures using electronic health records: Five case studies (Doctoral). Johns Hopkins Bloomberg School of Public Health.
Garets, D., & Davis, M. (2005). Electronic Patient Records EMRs and EHRs. Healthcare Informatics, 1-4. Retrieved from http://www.providersedge.com/ehdocs/ehr_articles/electronic_patient_records-emrs_and_ehrs.pdf
Glandon, G., Smaltz, D., Slovensky, D., Boxerman, S., & Austin, C. (2008). Austin and Boxerman's information systems for healthcare management. Chicago: Health Administration Press.
Health Information Technology,. (2013). Capturing high quality electronic health records data to support performance improvement (pp. 1-73). healthit.gov.
healthit.ahrq.gov,. Electronic Medical Record Systems | AHRQ National Resource Center; Health Information Technology: Best Practices Transforming Quality, Safety, and Efficiency.Healthit.ahrq.gov. Retrieved 25 March 2016, from https://healthit.ahrq.gov/key-topics/electronic-medical-record-systems
healthit.gov,. (2014). Definition and Benefits of Electronic Medical Records (EMR) | Providers & Professionals | HealthIT.gov. Healthit.gov. Retrieved 25 March 2016, from https://www.healthit.gov/providers-professionals/electronic-medical-records-emr
Keshavjee, k., Troyan, S., Holbrook, A., & VanderMolen, D. (2013). Measuring the Success of Electronic Medical Record Implementation Using Electronic and Survey Data. Practice Management, 1(3), 1-15. Retrieved from http://www.aafp.org/dam/AAFP/documents/practice_management/health_it_guides/MeasuringEMRSucess.pdf
