Session 5

Electronic Patient Records

Definition

Electronic patient record (EPR) is a file kept in a computer.

EPR is used to organize and keep information about the patient’s history, general health condition and other data that are relevant to patients.

Most public health facilities in Tanzania keep hard copies of patient records in physical files. Some health facilities are converting to an electronic (computer-based) medical records system.

Registration, Admission and Discharge

Specially designed software used to register out- and in-patients.

It is used to discharge a patient from the health facility after treatment.

The software is used in the

Outpatient area for registration of new case attendances and return case attendances.

All data pertaining to outpatient is recorded and stored directly in the computer.

In-patient area for registration of admissions.

In the ward, the software is used to keep records of number of admission, inter- wards’ transfers, patient discharge and death.

Medical billing is extremely complex, especially when a medical facility is handling billing to multiple insurance companies along with government agencies and private consumers, and all of these groups require different billing process.

The software is used to

Generate patients` bills

Track payments and overall patient and facility trends.

In the health facility, once a patient record is initiated in a medical billing software program, the patient history is entered in, along with outstanding unpaid charges.

The program automatically generates bills for patients, or for insurance companies, employers, and other individuals who may be paying the patient’s bills.

Electronic medical record-keeping facilitates billing through medical billing software.

Medical billing software interfaces with an electronic medical records system

Equipment (Hardware and Software) Requirements in the Health Facility for Smooth Functioning of Electronic Patient Records/Medical Billing

Special computer for health records, doctors, laboratory, radiology, pharmacy, wards, offices and finance

Fax machine

Information kiosk

Local area network/ Wide area network

Telephone

Special printers for health activities

For improvement of healthcare services, the electronic patient records software should be connected in all areas which provide health services to the patients

Changing from Paperwork to Electronic System

In many cases, when a health care practitioner wants to invest in computerized medical records, the paper medical records can simply be scanned and entered into a medical records system.

Instead of documenting patient information on paper and creating files and for extra storage space, electronic medical records are stored on a computer server.

Computerised medical records are accessed quickly and efficiently, eliminating the need for employees to physically look for the records in an office.

This saves medical service resources, since employees are no longer expected to lose time while retrieving records

Data that would have to be stored at a remote storage facility are easily entered into medical records systems and stored on a hard drive as well as on CDs for easy retrieval.

Electronic patient record (EPR) file are easier to transfer electronically from one area to another within a hospital and outside the hospital.

It improves efficiency in healthcare services, leading to a cost savings for both the patient and medical provider. For example, it reduces lost of examination results, medical documents, etc. from paperwork.

A doctor can access a computer in the treatment room and look at all vital and relevant information before rendering a diagnosis and prescribing treatment.

Doctor can put a prescription directly into the computer and immediately sending the order to the pharmacy of choice.

Information is saved and there is no need to worry about misplacing a file.

Emergency physician needs access to a patient’s medical history, and a doctor’s office is not open, an EPR may be available immediately.

This save lives by ensuring that an incapacitated patient is not given a drug he or she is allergic to or which reacts negatively with a medication the patient is already receiving.

Electronic medical records are easily accessible during emergencies and serve patient life.

Records are quickly updated for patients who have serious, progressive or chronic illnesses.

Patient with digital records do not have to worry about unsecured storage facilities or the loss of records through theft, accident or natural disasters.

It reduces waiting time leading to accessibility of medical service in time.

It saves time and money.

It helps health service provider to better serve the patient.

It reduces unnecessary work for employee to search for files.

Reduces the issue of medication errors.

Reduces miscommunication among health workers.

It facilitates billing through medical billing software.

It reduces risk of misfiling.

It is easy to compile statistics on the number of patients treated for a given illness or type of medications.

It assists in monitoring and evaluating the scope of practice and general quality of care offered by a physician and other paramedical staff.

It helps in financial control.

It provides healthcare data on time for planning and decision making

Provides materials for education

Provides ease access of research data

Unauthorized accessibility

Unauthorized person could access the record for illegitimate purposes.

The potential for abuse with electronic files is greater, because there is more opportunity for more people to access them, and information can be moved, analyzed and sold much more rapidly.

Electronic files, by their nature require access to computer, which, in turn, requires electricity. Thus, when electric power is unavailable, the records also would not be available.

Security

Patient information is confidential, and records systems need to develop ways to protect patients so that their medical records are not unnecessarily shared.

Cross-platform compatibility

The cross-platform compatibility is a large issue in using electronic patient records. For example:

When two medical offices use different electronic medical records systems, it may not be possible to exchange data between the two systems

System has difficulty converting or reading files written by older versions of the system or by different programs

Electronic patient record is a file kept in a computer, used to organize and keep patient’s records.

Electronic patient records are used in registering, intra transferring, discharging and billing of patients.

Electronic patient records are easily accessible, and save time and money.

Electronic patient records enable health care provider to quickly review patient history without going through large amounts of printed documents.

Challenges to EPR include unauthorized access for illegitimate purposes, and necessity for reliable source of power.

What is electronic patient record?

What are the uses of electronic patient record?

What are the advantages of using electronic patient records?

What are the challenges of using electronic patient records?