Electronic Health Record System Paper

An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs are a vital part of health IT and can:Electronic Health Record System Paper

  • Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
  • Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
  • Automate and streamline provider workflow

One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.Electronic Health Record System Paper

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An EMR system is defined as an electronic record of health related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one health care organization. They have the potential to provide substantial benefits to physicians, clinic practices and health care organizations (Agency for Healthcare Research and Quality, n.d). [1] another term used interchangeably with EMR is the Electronic Health Record (EHR) that are digital records of health information that offer more functions than EMRs as they focus on a patient’s total health not just the standard clinical data.

Background of the study

Despite electronic medical record (EMR) systems being in existence since 1972, it’s only recently that governments worldwide have begun to encourage digitalization of medical records. In Kenya, the Ministries of Health (MOH), i.e., the Ministry of Medical Services and the Ministry of Public Health and Sanitation, are actively promoting the standard implementation of EMR systems with the aim of improving health care delivery, health systems management and patient health outcomes. Several EMR systems exist in Kenya to collect and manage data, analyze data, manage patients or hospitals, provide administrative/management support and to manage external systems such as supply chain management.Electronic Health Record System Paper

Statement of the problem

Since the adaptation of EMR systems, numerous reviews for example (Ministry of Health Kenya, 2011) [2], have the systems not to address the minimum functional requirement categories which the EMR Standards and Guidelines for Kenya (ESG) deem important for defining standards for EMR systems. With EMR systems being the current way of hospital management and also delivering healthcare in KTRH, there is need for a review of their impact. This study aims at reviewing the functional uses and getting to know the impact of the EMR systems in KTRH.Electronic Health Record System Paper

Justification

Despite there being reviews on the EMR systems, there is limited knowledge on the perception of healthcare providers who use these systems especially in Kenya. This study aims at bridging this gap in knowledge in the field of health informatics in Kenya. The findings of this study have the potential to inform development of guidelines for upgrading the systems to meet international standards.

An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports   The EHR automates access to information and has the potential to streamline the clinician’s workflow.  The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.Electronic Health Record System Paper

EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians.  The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.

For example, the EHR can improve patient care by:

  • Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
  • Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
  • Reducing medical error by improving the accuracy and clarity of medical records.

Healthcare organizations across the United States have made the transition from paper-based document management systems to storing records electronically. An electronic health record (EHR) is a computerized collection of patient information in a digital format. The importance of electronic health records is that they facilitate sharing of patient data such as medical records, charts, medications and test results across multiple healthcare environments.Electronic Health Record System Paper

What Are the Benefits of Electronic Health Records?

Examples of the numerous benefits of electronic medical records in hospitals and other healthcare facilities include:

  • Improved Quality of Care: Computerized notes are often easier to read than a physician’s handwriting. This reduces the risk of errors and misinterpretations that can negatively impact the quality of patient care.
  • Convenience and Efficiency: Medical and office staff no longer have to waste time sorting through cumbersome paper records. Users can access electronic health records quickly and efficiently with just a few strokes on a keyboard.
  • Saving Space: Electronic health records eliminate the need to store documents in bulky file cabinets, which frees up more space in the office for medical supplies and equipment and other essentials.
  • Patient Access: Many EHR systems include a patient portal that allows patients to view their medical history and information whenever they wish.
  • Financial Incentives: Installing a certified EHR can help you fulfill the Meaningful Use requirements for Medicaid and Medicare, making you eligible for various incentives from the federal government.
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What Are the Disadvantages of Electronic Health Records?

There are also several disadvantages of electronic medical records, such as:Electronic Health Record System Paper

  • Potential Privacy and Security Issues: As with just about every computer network these days, EHR systems are vulnerable to hacking, which means sensitive patient data could fall into the wrong hands.
  • Inaccurate Information: Because of the instantaneous nature of electronic health records, they must be updated immediately after each patient visit — or whenever there is a change to the information. The failure to do so could mean other healthcare providers will rely on inaccurate data when determining appropriate treatment protocols.
  • Frightening Patients Needlessly: Because an electronic health record system enables patients to access their medical data, it can create a situation where they misinterpret a file entry. This can cause undue alarm, or even panic.
  • Malpractice Liability Concerns: There are several potential liability issues associated with EHR implementation. For example, medical data could get lost or destroyed during the transition from a paper-based to a computerized EHR system, which could lead to treatment errors. Since doctors have greater access to medical data via EHR, they can be held responsible if they do not access all the information at their disposal.

Electronic Health Record System Paper