The importance of medical records in health care delivery has been recognized for a long time. Its revelance to patient care and health administration was documented by Florence Nightingale in 1873 a book entitled Notes on a Hospital. Ideally the medical record should be the primary repository of all information regarding patient care, provide decision-support, and be a tool for support and maintaining ancillary health care activities such as administration, quality assurance, research and epidemiology. Shortliffe has defined medical (health) practice as medical decision-making, and it is recognized that there is an integral relationship between medical decision-making, the accumulation of clinical data, health care costs, patient outcomes, and the quality of care. TRADITIONAL MEDICAL RECORD SYSTEMS
Current medical record systems are predominantly hard copy paper-based models such as laboratory results and X-ray reports which can be read by only one person at a time and is difficult to store. It can be organised in one format at a time yet the demands of the users of the record require it to be in a multitude of formats to meet the individuals needs. Poor indexing of data makes the finding of information difficult or impossible.It was recently calculated in the U.S.A. to cost an additional $15 billion per year to manually reproduce the medical record by transcription. Use of the paper chart as a medical record impedes efforts to monitor and improve health care by the inherent difficulty, time, and expense required to access individual charts. TECHNOLOGY AND HEALTH CARE DELIVERY
Since the 1960s there has been a rapid growth in the technology used to support medical care, and this has resulted in the creation of enormous volumes of data and information that is available to assess and manage the delivery of health care. New and evolving technologies continue to produce and store large volumes of data and information for patient care, but there only a few systems that provide information processing tools which support clinical decision making. It is recognised that information processing capacity of the human brain is limited in its ability to accurately decipher this clinical data and information in a timely manner without errors. Errors in decision making are further increased when there is random noise data. The use of predominantly manual, non-integrated medical records systems has led to increasing costs in patient care and administration, decreased compliance with health care standards, inappropriate variation in health care delivery, and possible negligent behaviour by health care providers. CONCEPT OF ELECTRONIC MEDICAL RECORDS (EMR)
EMR is the storage of all health care data and information in electronic formats with the associated information processing and knowledge support tools necessary for the managing the health enterprise system. In the early 1970s several institutions investigated the concept of creating an EMR to improve patient care. An important feature was the concept that the medical record should be the cornerstone for all information systems within the health care environment. One of the earliest successful implementations of EMR functions was at the Regenstrief Institute, Indianapolis. Using the Regenstrief Medical Record System (RMRS) McDonald demonstrated that the use of computer-generated reminders based on patient-specific laboratory data resulted in a reduction of physicians errors in the detection of life-threatening events, and also confirmed that busy physicians were often unable to detect many of the critical abnormalities occurring in the patient record. Computer-generated reminders are now used as standard tools for patient care in the RMRS and other EMR systems used in hospitals and ambulatory care environments. THE INSTITUE OF MEDICINE STUDY INTO ELECTRONIFICATION OF THE PATIENT CARE RECORD In 1992 the Institute Of Medicine of the American National Academy of...
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