Medical Records and the Implementation of Health Informatics

Topics: Electronic health record, Health informatics, Medical informatics Pages: 7 (1743 words) Published: November 14, 2010

Health Informatics or Medical Informatics is the intersection of information science, computer science, and health care. Health Informatics offers resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. The applicable areas would be nursing, clinical care, dentistry, pharmacy, public health, and bio medical research.

Electronic health information systems are the science that addresses how to use information to improve health care. This paper will present the concept of electronic health records (EHRs) and the current developments and analysis of the transition and implementation of health informatics in health care organizations in the United States and globally.

The analysis contains a brief overview of the affects of physicians and their practices in relation to their adaptation to EHRs. This paper addresses the issue of the security of EHRs, and the efficiency and costs of electronic prescribing.

Clarification of Electronic Medical Records and Electronic Health Records

Electronic Medical Records and Electronic Health Records are two different concepts.

The data in the EMR is the legal record of what happened to the patient during their encounter at the care delivery organization (CDO) and owned by the CDO. The EHR environment relies on functional EMRs that allow care delivery organizations to exchange data/information with other CDOs or stakeholders within the community, regionally, or nationally (Davis & Garets, 2006).

The EHR’s are composed of other records and documents owned by the patient, and allow patient access within a community, region, state or national. \
In the 2005 EMR adoption model, there are seven stages towards the completion transition. Many U.S. hospitals have not reached stage 1 or 2 of the EMR Adoption Model. Without the effective and efficiently implementation of the stages of the EMR Adoption Model, clinical systems will be unable to participate in EHR initiatives. “How can we discuss the potential of EHRs, much less implement them, until we have implemented effective EMRs, not only in hospitals, but in all care delivery organizations including physician practices” (p. 14)?

Ehealth is a form of technology, which includes the areas of Health Informatics, Electronic Medical/Patient Records, Clinical Decision Support, and Telehealth.

The main purpose of eHealth is to provide better use of information in health care settings, to improve the quality of patient care and the efficiency of clinical processes (Maeder & McGregor, 2009).

In the United States, most medical records are stored on paper. These paper records cannot be reference to coordinate care, routinely measure quality, or reduce medical errors. With the adoption of EMR will lead to major health care savings, reduce medical errors, and improve health care.

How Secure are Electronics Records

“Paper medical records are difficult to secure and keep private—records can be left unattended on people’s desks, inadvertently placed in the trash, or transported among clinician offices via taxicabs or other couriers,” Brailer said. “Even when they are in secure facilities, it is not possible to restrict viewers to only the information they need to see to do their work. We rarely can identify when privacy of paper records has been compromised” (p. 7). The use of audit trails, access permissions, and viewing restrictions with electronic record systems prevent the misuse or unauthorized access.

The issue of security concerning paper health records has not been as scrutinized as the security of electronic health records.

Electronic systems offer a quantum leap in the beneficial uses of medical records, by allowing the full value of all information ever written down or stored as images at many sites of care to be indexed and utilized by multiple caregivers in multiple locations...
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