How to Manage Electronic Health Records - ByteScout

How to Manage Electronic Health Records

An electronic health record is a digital collection of medical information about a patient’s systematized health histories, such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans by a particular physician, nurse practitioner, specialist, dentist, surgeon or clinic.

Electronic health records are easily confused with electronic medical records. However, an electronic medical record is a single practice’s electronic copy of a patient’s chart. These electronic medical records are typically used by providers for diagnosis and treatment but are not designed to be shared outside the individual practice.  Electronic health records are made for authorized portability and allow a patient’s medical information to be shared with specialists and other health facilities if necessary.

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Since an electronic health record is a repository of the patient’s medical history, therefore, is important for all health providers to treat the patient.  They can use the records to gain insights into the patient’s conditions and therefore make the appropriate recommendations about the patient’s care. These records are shared via enterprise-wide information systems or network connections, or other information networks and exchanges.

Electronic health records have software programs that make it easy for health professionals to use when compared to alternatives such as traditional record keeping. These are typically accessed on a computer and may include a range of data such as daily vital signs to personal information like age and weight, and billing information. This type of information, when recorded by handwritten methods, may have less legibility and accessibility since doctors have to waste time searching through several files.

However, the compilation of such data through computer management programs offer clinicians a snapshot of the patient’s clinical data that helps to improve outcomes as well as giving clinicians the ability to identify and stratify chronically ill patients.

In the future, it is thought that electronic health record software will have advanced analysis systems such as artificial intelligence to make assessments and evaluations with patient data, predicting the risk of diseases and preventing the hospitalization of these high-risk patients.

Electronic health record systems are made in a smart way. The software is able to store data accurately and collect information about the state of a patient across time. It also adds longevity because other physicians can care for the same patient and gain insights from access to their health records. Additionally, it cancels out the tracking down of a patient’s previous paper medical records while making sure the data collected is accurate and legible.

It reduces the chance of data replication since there is only one modifiable file. This has two benefits, updated documents and decreased risk of losing paperwork. Improved functionality is also a bonus, most software of this type allows information to be searched for through the patient records and ease of extracting medical data thus saving time and improving the effectiveness of any further diagnosis.

Types of electronic medical records

There are two main types of electronic health record systems both provide different functionalities. It has been suggested that before hospitals or healthcare organizations choose software to install, there must be much deliberation. The advantages of the system should be in line with the goals and targets of the organization.

Cloud-based electronic health record systems are more novel when compared with locally hosted electronic health record systems. Cloud-computing platforms typically provide higher levels of IT service availability, reduced initial hardware and software costs as well as ongoing maintenance costs.

This type of electronic health record system also enables a quicker launch of the system since there is a short installation time and only training is required. The only drawbacks are issues with data security and lower levels of data control, these become a shared responsibility with the cloud-based electronic health record system provider.

Locally hosted electronic health record software and data are housed on server computers at the given location such as a hospital. With this system, there is less reliance on the internet and no need to trust an outside organization with the security of patients’ data. However, this also means that performing regular data backups and keeping servers secure will be the sole responsibility of those inhouse.

How to manage electronic medical records

As shown above, electronic health record systems are either cloud-based or have local servers. Before the installation of the software, there must be a project plan and process involving the staff as well as patients, a redesign of workflows, and adequate training.  This ensures the effective implementation of the electronic health system.

During the implementation phase and after installation, determine how to backload patient medical histories, how to tailor the system to current needs, how to establish a change-management process, and most importantly giving time to the staff and patients to adapt to the new system.

Once installed, electronic health record systems are readily useful in maintaining electronic health record information of patients for healthcare providers in hospitals, clinics, and other medical facilities.  The electronic health record systems are managed by keeping them updated, regularly backing them up and ensuring functionality so they can perform the following tasks:

  • Identifying and maintaining a single patient record for each patient.
  • Creating and maintaining patient-specific problem lists.
  • Creating and maintaining patient-specific medication lists.
  • Managing patient history, consents, and authorizations, clinical documents, and notes
  • Generating and recording patient-specific instructions before and after procedures and post-discharge requirements.
  • Submitting diagnostic test orders based on input from specific care providers.
  • Notifications and reminders for healthcare workers as well as patients.
  • Clinical task assignment and routing, clinical task linking, clinical task tracking, and inter-provider communication
  • Facilitation of communication between healthcare providers
  • Patient education.

There are several challenges when managing electronic health records. Some of these are data and privacy breaches,  medical identity theft, and patients’ fear of the integrity and privacy of their health information. However, the potential future benefits of electronic medical records are immense.

Improvements in the user interface, cybersecurity, integrated workflow with clinicians’ tasks as well as increased interoperability between electronic health record systems and patient’s mobile technologies will go a long way in improving electronic medical records.