by Kanchana Akmeemana

Created on: October 27, 2010   Last Updated: October 28, 2010

Many health care institutions are seeking to develop integrated clinical workstations. There are single-entry points into a medical world in which computational tools assist not only clinical matters but also administrative and financial topics, research and even scholarly information. The key idea, however is that at the heart of the evolving clinical workstation lays the medical record in a new incarnation.

An electronic health record is a repository of electronically maintained information about an individual’s lifetime health status and health care, stored such that it can serve the multiple legitimate user of the record. Traditionally, the patient record was a record of care provided when a patient is ill. Managed care encourages health care providers to focus on the continuum of health and health care from wellness to illness and recovery. Consequently the record must integrate elements regarding a patient’s health and illness acquired by the multiple providers across diverse settings.

A computer based patient record system adds information management tools to provide clinical reminders and alerts, linkages with knowledge sources for health care decision support, and analysis of aggregate data both for care management and for research.

To use a paper based patient record, the reader must manipulate data either mentally or on paper to glean important clinical information. In contrast an electronic HR system provides computer-based tools to help the reader organize, interpret, and react to data.

Electronic HR is flexible and adaptable – data may be entered in a format that simplifies the input process and displayed in different formats suitable for their interpretation. Further it can integrate multimedia information such as radiology images and echocardiography video loops that were never part of the traditional medical record. Data can be used to guide care for a single patient or in a aggregate form to help administrators to develop policies for a population.

An electronic HR system extends the usefulness of patient data by applying information-management tools to data.

When the data are stored on a secure network, authorized clinicians with a need to know can access them from the office, home or emergency room to make timely informed decisions.

Documentation can be more legible because it is recoded as printed text rather than as handwriting and it is better organized because the structure is imposed on input.

The computer can even improve completeness and quality by automatically applying validity and required field checks. Moreover, an interactive system can prompt for additional information.

Data entered can be reused. For example, a physician could cut and paste parts of their visit note into a referring letter.

Leaders in all segments of health care industry must work together to articulate the needs, to define the standards and to write laws to accelerate the development and routine use of Electronic HR system in health care.

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