ELECTRONIC MEDICAL RECORDS

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ELECTRONIC MEDICAL RECORDS

• By Sh. Ananthakrishnan
• Technical Director, NIC

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Medical Records Objectives

• Review patient care, appropriate take clinical
  decisions develop treatment plans
• Provides an archival and legally acceptable
  record
• Provides material for researchers
• Act as a source of information for heath
  administrators

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Medical Records Objectives

• Enables for hospital auditing
• Be stored in such a way that it is available when
  required
• Be subject to access controls to protect patient
  privacy, to avoid un-authorized/misuse

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Medical Records Present status

• The (paper) medical record is an abomination it
  is a disgrace to the profession that created it.
  More often than not the chart is thick, tattered,
  disorganised and illegible progress notes,
  consultants notes, radiology reports and nurses
  notes are all co-mingled in accession sequence.
  The charts confuse rather than enlighten they
  provide a forbidding challenge to anyone who
  tries to understand what is happening to the
  patient.
• Bleich,H

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Medical Records Present status

• Finding and reusing key data items
• Record fragmentation
• Movement of paper information
• Lack of support for decision support systems

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Medical Records

• The safe and cost-effective practice of medicine
  is becoming increasingly complex, and relies more
  and more on knowledge of the results of recent
  research into causes, manifestations, diagnosis
  and effective treatment of illness.

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Medical Records

• Knowledge-based decision support tools are
  increasingly being used and are likely to prove
  invaluable as a means of ensuring and assuring
  best quality care and practices for all patients.
  However, the only efficient way of using them is
  to hold the medical records in an electronic form
  with which these tools can interact directly.

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Electronic Medical Records

• Availability, transfer and retrieval
• Linkage
• Storage
• Data Views
• Abstraction Reporting
• Data Quality and Standards
• Decision Support

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Obstacles Electronic Medical Records

• Technology Investment
• Adoption by the user
• Modification of existing practices
• Understanding of legal and ethical issues
• Holistic view of the service to the patient

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Medical Records

• Computer networks for electronic exchange of
  medical records
• PACS
• HL7 and DICOM standards
• Computerized medical reporting systems
• Smart cards
• Web based medical reocrds availability

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Medical Records Where we stand

• Present status of medical records in Govt.
  hospitals
• Non-availability of medical records for OPD
  services
• Non-availability of area-specific morbidity
• Integrated diseases surveillance system
• Health infrastructure assessment National
  commission for macroeconomics and health

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• THANK YOU