WOMENS-HEALTH Messages for November, 2008: GENERAL: Article on Electronic Health Record

GENERAL: Article on Electronic Health Record

From: albons (anonymous@obgyn.net)
Wed, 19 Nov 2008 05:55:03 -0600 (CST)

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An Electronic Health Record (EHR) refers to an individual patient's medical record in digital format. Electronic health record systems co-ordinate the storage and retrieval of individual records with the aid of computers. Introduction - "What is an EHR"? An Electronic Health Record (EHR) refers to an individual patient's medical record in digital format. Electronic health record systems co-ordinate the storage and retrieval of individual records with the aid of computers. EHRs are usually accessed on a computer, often over a network. It may be made up of electronic medical records (EMRs) from many locations and/or sources. A variety of types of healthcare-related information may be stored and accessed in this way. Types of Data stored in EHR: An electronic medical record might include: 1. Patient demographics. 2. Medical history, examination and progress reports of health and illnesses. 3. Medicine and allergy lists, and immunization status. 4. Laboratory test results. 5. Radiology images (X-rays, CTs, MRIs, etc.) 6. Photographs, from endoscopy or laparoscopy or clinical photographs. 7. Medication information, including side-effects and interactions. 8. Evidence-based recommendations for specific medical conditions 9. A record of appointments and other reminders. 10. Billing records. 11. Eligibility 12. Advanced directives, living wills, and health powers of attorney Advantages of EHR over paper records: 1. Medical records may be on "physical" media such as film (X-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure and may violate the patient's HIPAA privacy 2. Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage 3. When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant, as are the concerns of HIPAA compliance 4. Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors. Pre-printed forms, the standardization of abbreviations, and standards for handwriting were encouraged to improve reliability of paper medical records. 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 5. In 2004, an estimate was made that 1 in 7 hospitalizations occurred when medical records were not available. Additionally,1in5lab tests were repeated because results not available

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Next message: JTR: "OVARIANCYST/FIBROID: After ultrasound ob/gyn isn't sure if I have an ovarian cyst or uterine fibroid"
Previous message: jazzylady: "Re: Dr. Goldfarb: RE: can dr. explain how pelvic irritation can refer as rectal pressure/pain??"

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