ACCESIBILITY, RESPONSABILITY

GLOBAL TECH DOCTOR

Electronic Medical Records

 

Electronic medical record (EMR) is a systematic collection of electronic health information about an individual patient or population. It is a record in digital format that is capable of being shared across different health care settings. The communication can be by way of network-connected, enterprise-wide information systems and other information networks or exchanges.

EHRs includes a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, age and weight, and billing information.

The system is designed to collect data that captures the state of the patient at all times. It allows for an entire patient history to be viewed at-real time. The data is accurate and legible.

 

In the US Federal and state governments, insurance companies and other large medical institutions promotes the adoption of electronic medical records. The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare or up to $65,000 over six years, under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements for covered patients to doctors who fail to use EMRs by 2015) for EMR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.

The United Nations World Health Organization (WHO) administration does not contribute to an internationally standardized view of medical records. WHO contributes to minimum requirements definition for developing countries.

The United Nations accredited standardization body International Organization for Standardization (ISO) has settled standards in the scope of the HL7 platform for health care informatics. Respective standards are available with ISO/HL7 10781:2009 Electronic Health Record-System Functional Model, Release 1.1 and subsequent set of detailing standards.

Handwritten paper medical records are associated with poor legibility, which can contribute to medical errors. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.

In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.

 

Health Information Exchange:

• Technical and social framework that enables information to move electronically between organizations

• Reporting to public health

• ePrescribing

• Sharing laboratory results with providers