There are distinctive functions related to the health records of patients. The patient’s record is used to document care and providing legal as well as financial information. Patient health records help in research activities and are also useful for qualitative purposes. All types of information related to the patient must be shared among concerned professionals who are involved and included in the healthcare team (Catalano, 2006).
The need for the development of mechanized health records is becoming more obvious and ostensible nowadays. The system of electronic health care is supportive in providing huge opportunities for organizations involved in healthcare. Through electronic health records, they can focus more on improving the quality associated with health care and also ensure the safety of the patients (Pardes, 2006).
One of the greatest challenges in today’s world in delivering effective healthcare is to provide reliable, pertinent, timely, accurate, accessible, and manageable information to everyone involved in healthcare. It is equally useful for healthcare team members including; members providing primary as well as secondary care; nurse; doctor; patient; and health professional.
The electronic health record is, in fact, longitudinal data of entire healthcare provided to the patients during a specified period. As such, electronic health records should be designed to decrease inefficiencies in an environment and also reduce costs to a huge extent. It is believed that the first medical record was created and maintained by Hippocrates in the 5th century B.C. Hippocrates focused on accomplishing two goals for maintaining medical records; it should exhibit the course of disease accurately and should specify the possible cause of disease. However, these two goals are also adequate in the modern world, although electronic health record also supports in providing improved functionality and performance such as interactive flow sheets and alerts, etc. These functionalities cannot be done without a particular paper-based system (Rajeev, 2008).
Electronic health records support the administrator of the healthcare organization to acquire billing information, requirements by physicians to observe the effectiveness of treatment, and a researcher can analyze the effectiveness of medications. In case every professional works on a different set of information, it will become complex to portray the complete picture of the patient’s state. Electronic health record integrates all information to cater to different requirements with the primary goal is to collect information on a one-time basis and then use it regularly.
Another major purpose of Electronic health records is their utilization in complicated hospital and clinical environments. Characteristics along with interfaces that are highly adequate for one particular medical specialty could not possibly be used in another. The information collected and presented, the level of detail, and the sequence of presentation could be exclusively distinctive, depending mostly on the user and venue.
The system of electronic record could be developed individually for every service received by the patient from all related departments including laboratory, pharmacy, or radiology. Moreover, some clinics also permit the gathering of physiological indications, physician orders, as well as nursing notes. These electronic records are mostly not integrated; rather they are captured and kept in specific silo systems (Carter, 2008).
Advantages and Disadvantages
An electronic health record system signifies a huge possibility of reduction in costs as well as decreasing inefficiencies in the working environment. Since electronic health record is relatively a new theme, there are some disadvantages, obstacles, hindrances, and obstacles in the accomplishment of the objectives set for it. Although there have been exceptional technological and scientific advancements, the documentation about the patient is still viewed as the same.
Although technology provides huge support to electronic health records, there are certain obstacles required to be removed for accomplishing the goal of implementing electronic health records successfully. Technological advancements are still being made at a swift pace, but many humans, as well as organizational issues, are yet to be addressed effectively. This slow pace has affected the process of implementing a mechanized system of electronic documentation.
There are certain advantages of electronic health records as compared with keeping health records on paper. A significant benefit is that there are continuous storage possibilities specifically for longer periods. Moreover, the electronic health record system is accessible from different remote areas to many individuals at the same time, and retrieval of data is almost instant. The record of patients is updated regularly and available to be used by anyone and everywhere. Data is instantly accessible at any particular workstation as and when required.
The paper record exhibits huge fragmentation of information related to clinical health. This not only results in an increased cost of information management but leads to an increase in overall costs because of its negative impacts on the present as well as future healthcare. The electronic health record is also used in providing reminders and medical alerts. This system has specific in-built intelligence abilities like identifying abnormal results of laboratory, or possible drug interactions. Findings by different studies focusing on diagnostic tests and the electronic health record can be associated with the health professionals to care plans, literature databases, protocols, and other pharmaceutical information related to healthcare knowledge. Computers are not supposed to replace vital diagnoses and judgments made by doctors, however, an electronic health record system supports in collecting and disseminating data to support the physicians in decision making.
Another advantage of an electronic health record system is that it facilitates customized opinions of data relevant to the needs of different specialties. The system is flexible and supports its users to utilize tailored formats of reporting and organize as well as exhibit information in many ways. Electronic health record, as an effective technique of management, provides critical information to improve the evaluation results. However, there are certain disadvantages associated with the electronic health records system. A significant disadvantage is the initial costs for setting up the system. The cost could be quite high. As healthcare organizations strive to reduce their overall costs, utilizing financial resources for this information system is considered a huge challenge (Amatayakul, 2004).
Another disadvantage is that there exists a large learning curve and it is supported only if the users possess some technical knowledge. In the modern medical world, clinicians are regarded as the primary and extensive users of electronic health records systems contrary to the major users in the history in which clerks were supposed to do this job. The disadvantages of the electronic health record system can be summarized as; it is expensive; initial expenses are much higher; lack of employee acknowledgment and adaptation can fail, and systems can be time-consuming as well as confusing and complicated.
Challenges and Future
A significant challenge is related to the issues confronting electronic health records systems is the phenomenon that physicians or doctors should be the users of the system. They must perform the work of data entry such as progress notes, noting orders, etc. Moreover, physicians must be capable of retrieving information if they want to benefit from the online interactive support.
The factor of ‘usability is considered as another significant challenge impacting the process of implementing an electronic health records system. Necessary tools should be available so that the clinicians can understand as well as retrieve information related to their work of decision making. Or it can be said that electronic health records systems should be user-friendly. In case they are not user-friendly the systems will not be adapted and utilized to their full capacity.
However, despite the disadvantages and challenges, the future of electronic health records systems is promising as clinicians have started accepting the cultural shift i.e using a mouse instead of a pen. Moreover, they have acknowledged the advantages of an organized database and improved communications.
- Amatayakul, M (2004) Electronic Health Records: A Practical Guide for Professionals and Organizations
- Carter, J (2008) Electronic Health Records, American College of Physicians
- Catalano, J (2006) Nursing Now! Today’s Issues, Tomorrow’s Trends. Philadelphia, F.A
- Davis Pardes, H (2006) Aspects of Electronic Health Record Systems, Springer, 2006
- Rajeev, K (2008) Electronic health records approaches and challenges. International Journal of Electronic Healthcare, 4(1)