HIBBs is a program of the Global Health Informatics Partnership Introduction To Electronic Medical Records Y. SINGH NELSON R. MANDELA SCHOOL OF MEDICINE DEPARTMENT OF TELEHEALTH Content licensed under Creative Commons Attribution-Share Alike 3.0 Unported

Learning Objectives What a electronic medical records Disadvantages of paper based records Examples of electronic medical record system How to assess the benefit of a computer based record system

Introduction Medical chart or medical record Comes from the idea of patient information Why should a doctor write these notes? Too recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, to justify interventions

Organisational:  Information storage and retrieval Logistical:  Wear and tear  Back-ups  Can only be at one place at a time Research Passive nature Disadvantages of paper records

Electronic Medical Records EPR - Electronic Patient Record EMR - Electronic Medical Record CbPR - Computer-based Patient Record CPRS - Computer Patient Record System EHR – Electronic Health Record

What’s the Difference? What is the difference between a CPR and an EMR? Patient orientated

Comments by Clinicians Video One and Two

Technology Intervention Use of database technologies  Information retrieval  Different levels of use  Structured vs unstructured  Scheduled back-ups Semi or automatic data entry  Voice, handwriting recognition, direct entry via keyboard  Templates Data communication

Technology Intervention Security  Unwarranted fear  Strong passwords  Encryption and digital signatures Clinical decision support systems Cost savings Improve quality of care

BUT ….

Problems Technology:  Infrastructure  Training and expertise  Perception Human Factor  May create discord Change management

Assessing Benefits Are all EMRs benificial? NO Comprehensiveness of information Duration of use and retention of data Degree of structure of data Ubiquity of access Workflow Etc etc etc etc etc etc etc etc etc etc etc …

Components of a EMR Integrated view of patient data Clinician decision support Clinical order entry Access to knowledge resources Integrated communication support

Issues with CPR – Data entry Data Capture Data Input Error prevention

Issues with CPR – Data Display Bruce Slater

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