ELECTRONIC MEDICAL RECORDS By Sh. Ananthakrishnan Technical Director, NIC

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

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

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, consultant’s 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

Medical Records – Present status  Finding and reusing key data items  Record fragmentation  Movement of paper information  Lack of support for decision support systems

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.

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.

Electronic Medical Records  Availability, transfer and retrieval  Linkage  Storage  Data Views  Abstraction & Reporting  Data Quality and Standards  Decision Support

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

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

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

THANK YOU