Computer systems used to register, deliver and manage patients. personal health information is known as electronic medical records (EMR). Any information obtained during a visit to a doctor, including a medical history, exercise, laboratory tests, prescriptions, referrals, and procedures performed in an office, hospital, or clinic, can be transferred to computerized patient records (CPR). This data may also include biopsies, imaging, specimen testing, and diagnostic testing procedures.
Medical documentation methods have evolved over the past 50 years, and the concept of a medical medical record (EMR) was first introduced in 1969. In the early 1960s, most doctors used handwritten notes in charts to register patients. With the development of a mini-cassette in 1967 and a micro cassette in 1969, doctors and hospitals began accepting dictation / transcription, which allowed for more legal and thorough documentation of medical histories and examination results. With the advent of digital computer technology, we have entered the era of EMR and EHR (electronic medical record).
Another important step in the management of medical records was the development of a health assessment system through logical processing (HELP) in the late 1960s. This integrated hospital information system supported decision making for healthcare professionals and demonstrated that computer systems can not only replace paper documents, but also improve the care process by increasing the use of records.
In 1991, the Institute of Medicine published Recording on a Computer Patient: the most important technology in healthcare. This semantic document presents drawings for future computerized patient registration (CPR). In a revised version of 1997, the expert committee examined the potential of NGN to improve diagnostic and care solutions, provided a database for policy development and tried to answer these questions:
- Who uses patient records? - What technologies are available and what further research is needed to meet the needs of users? needs? - What should governments, medical organizations and others have to do in order to move to the SPP?
In 2003, the Committee on Medicine "Quality of Health in America" (IOM) filed a report entitled "Patient Safety: Achieving a New Standard of Care." In it, IOM called on hospitals and doctors to accept EMR as an important step towards preventive medical errors.
Also in 2003, the RAND Health Information Technology project launched an EMR study with two objectives:
1. To better understand the role and importance of EMR in improving health care.
2. Promote government actions that can maximize the benefits of EMR and increase their use.
The RAND study estimated potential savings, costs and benefits for the health and safety of EMR if they were accepted widely and efficiently. Some of the main research findings included:
- Medical information technology would save money and significantly improve the quality of healthcare. - Annual savings from efficiency alone can exceed $ 77 billion. USA. - Health and safety benefits can double the savings while reducing illness and prolonging life. - Barriers to the introduction of EMR include market incentives, because in general those who pay for health information technology do not receive the appropriate savings.
In response to these findings, the federal government turned to improving the quality and efficiency of health care and found that most Americans will have EMR within ten years. But, despite the participation of numerous federal agencies, electronic systems were adopted by only a small number of doctors and hospitals. The New England Journal of Medicine reported that in a 2008 study out of 2,758 primary care physicians, only 4% reported having an extensive, fully functional electronic recording system, and 13% reported having a basic system.
According to a 2004 study by Miller and Sima, private practice slowly accepted EMR due to early start-up costs and uncertain financial gain. They noted that the initial cost of EMR ranged from $ 16,000 to $ 36,000 per doctor. In the first weeks of using the new system, many practitioners also see fewer patients and spend more time entering data into their EMR, which leads to longer working days.
District hospitals or testing centers experience data exchange problems with EMR and laboratory or radiological systems. The necessary computer programs for such exchanges are either unavailable or costly to maintain and update.
Despite these barriers, there are many advantages to introducing EMR into private practice. Projections based on statistical models indicate that health information technologies can help in a radical transformation of health services, which will make it safer and more efficient.
My personal experience with EMR was positive. In 1996, after fifteen years of private practice in podiatry, I moved from the dictation / transcription system at MD Logic, Inc., to an electronic medical documentation system. During the first year, I realized the profit from my investments as a result of more accurate coding and increasing the efficiency of office work, as well as an increase in the number of calls related to improved communications with medical specialists. The most significant effect, however, was improving the quality of care for my patients. As the sub-diabetic knowledge base developed, I was able to spend more time face-to-face with my patients and less time to document.
In 2006, I transferred my group practice to MD Logic Worldwide EMR, a fully functional EMR. This allowed our office to become paperless. All components of a patient's medical record are stored on a hard disk and accessible from any computer in all our offices. Optimization of the work flow and elimination of redundant tasks were solved as a result of a significant increase in efficiency and employee relations. Instant access to patient's medical data and insurance information has proven to be an invaluable resource. In addition, the creation of an interface allows you to transfer information from a medical card to billing software for practice management.
Currently, the future direction of EMR appears to be in the hands of the government. The US Recovery and Reinvestment Act of 2009 provides significant monetary incentives to physicians who implement electronic medical records. However, in order to qualify for these incentives, the physician must not only have the proper software, but also engage in the “meaningful use” of the software. The government plans to publish criteria for meaningful use in February 2010. In 2011, ARMA-stimulants for doctors will begin.
Early EMR users were able to take advantage of the many benefits of this innovative technology in preparation for medical care in the 21st century. Doctors now have a tool that can significantly improve their medical results and the quality of life of their patients.
