Medical Record Keeping

What are the problems with America’s current medical recordkeeping system? How would electronic medical records alleviate these problems? The majority of America’s current medical record keeping is paper based which creates a lot of problems like:

a. Recordkeeping became really difficult with growing numbers of patients and their visits to Medical Practitioner. There are shelves full of folders and papers in corridors.

b. It makes it difficult to effective communication, referring and access to the records. During emergency it could be the matter of life and death.

c. It’s difficult to systematically examine and to share the information; the updating of these records is almost a challenge. There are cases of wrong entry and duplicate entries etc.

d. When a patient changes a Doctor or moves to other problems, it becomes a hassle for patient as well as for Doctor.

The electronic medical records will allow patients to enter their basic medical data into an online site initially and after that Doctor also will be able to send relevant information for regular update. This system will make record keeping more effective and streamlined which are easily accessible.

The use of electronic record keeping reduces errors in medical records. The handwritten records are subject to lots of human errors due to misspelling, illegibility, and differing terminologies. Thus digitations and standardisation of records will make the information universally accessible and cost effective too. Apart from this, it could also be used for remainder message for refilling of prescription, directories for doctors and personalised health advice. 2. What are the pros and cons of electronic patient records? Do you think the concerns over digitizing our medical records are valid?

Why or why not? The main proponents of electronics patient record cite the following advantages:

a. The electronics patient records reduce errors in medical records. With the use of electronics patient records standardization of patient health records may eventually become achievable.

b. Paper records can be easily lost. Digital records can be stored virtually forever and can be kept long after the physical records are gone. Electronics patient records also help keep records of health information that patients tend to forget with time, i. e. inoculations, previous illnesses and medications.

c. Electronics patient records make health care cost-efficient by consolidating all data in one place. Previously, paper-based records are located in different places and getting access to all of them takes a lot of time and money.

d. Electronics patient records can save lives. It enables rapid identification of at-risk patients and access to their medical history, thereby enabling rapid diagnosis and treatment especially in emergency situations. Classic examples are people with diabetes and/or heart problems who have high risk of collapsing and having attacks.

The disadvantages of Electronics patient records: Electronics patient records threaten privacy. Many people are uncomfortable about having their entire medical history recorded and digitized for almost just anybody to see – in other words, incursion into people’s privacy.

a. Medical data can be used against a person in some cases, be it for a job application, insurance coverage or a college scholarship. Although it is against the law to discriminate against people with illnesses and disabilities, it is a fact of life that the fitter you are, the more competitive you are in the job market.

b. Electronics patient records can lead to loss of the human touch in health care. In the process of digitalization, the interpersonal aspect in health care may be lost. The doctors are forced to think in categories and can seldom express a personal opinion on an individual case.

c. Electronics patient records are not that efficient. Despite efforts in digitalization and standardization, but sometimes one clinic’s EMR system is not compatible with that of a general practitioner or another clinic’s system, thus belying the claim of added efficiency

d. Electronic medical records are not safe and secure. Google Health and HealthVault are quick in assuring patients of the safety of their online health accounts. Stories of data hacking, stolen identities and blackmail abound. Even high security databases such as those run by banks and credit institutions are often compromised.

Should people entrust Google with their electronic medical records? Why or why not? People should adopt Google’s electronic medical records as it allows patients to control their medical records.

If they decide to change doctors or hospitals, they will be able to electronically transfer their Google records by themselves. There are a lot of advantages that has been discussed in above questions which will benefit people and the whole system. Some concerns like privacy and security of data is restricting people to adopt this; they wonder whether hackers will be able to access the Google medical records or whether the company will use them commercially. Google has assured that it will not share or sell the data, and it’s absurd to think Google would attempt to use medical records for commercial purposes.

Further, hacking into hospital, small clinic, or family practice computer systems is far easier that going after Google’s data centre. Google’s reassurances that its security is iron-tight and that businesses and individuals should have confidence in its ability to store and protect data. Based on these facts people should trust Google with their records.

If you were in charge of designing an electronic medical recordkeeping system, what are some features you would include? What are features you would avoid? The features which should be included in an electronic record keeping system are:

a. It should store and manage the medical and health information in one central place.

b. It should be personalized i. e. the patient decides what goes on the record.

c. It can give doctors fast and easy access to the patient’s records but only if the patient allows it.

d. It can import electronic records from hospitals and pharmacies that are Google Health-enabled or are registered Google Health partners.

e. It should be completely free.

f. It should be secure.

g. The system will have record standardization and interfaces can be customized to each provider environment.

This customization should be done so that a physician’s input interface closely mimics previously utilized paper forms. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs.

h. All together features that should be included are security, universal standards for gathering, storing, and disseminating data, and universal standards for transmission technologies. Some features to be avoided are unrestricted access to data and unencrypted transmissions.