Good Example Of Electronic Medical Record Essay

Shifting from a pen and paper medical records system into an entirely paperless one can be a real challenge for the entire hospital record keeping department. Most of the time, hospitals would want to retain the current hospital records in their pen and paper form and then keep all future hospital and patient records using the new paperless electronic medical records system that they will use, whatever that system is and whoever developed it is.
This is because converting pen and paper-based medical records into their electronic form can be more time-consuming and complex than creating new records using the new system . However, there are certain states that require hospitals, clinics, and medical institutions to keep both a virtual and a pen and paper-based form of medical health and patient records. The rationale behind this is so that the physical forms of documents can serve as a backup that may also be readily available for use of the department (and the hospital as a whole) should something happen to the paperless record keeping system, or in cases where the integrity of the data stored in the record keeping system gets compromised. In this paper, we are going to assess the different facets of converting a pen and paper-based hospital document, a record to be specific, into an electronic document.
The first question that one must address is how long it would take for the person who will convert the physical document into a virtual one. In this case, since the type of document that we are dealing with is just a simple patient chart or record, it should take between one to two hours of manual conversion only. By manual conversion, we mean that the builder would have to scan all the applicable information from the physical form of the chart and feed it into the electronic medical record keeping system. For example, the patient’s name, age, gender, and other pertinent demographic information must be manually obtained (i.e. from the physical document) and then typed in into the system. The estimate was mainly based on the average speed that a builder would take to scan and type in the information into the system, the complexity of the document that is being converted, the amount of data inside the document, and of course, the user friendliness of the electronic medical record keeping system that is being used. Naturally, the more user-friendly the system is, the faster the process would be .
There are two main challenges that people working in a medical institution’s record keeping department may encounter when it comes to the process of converting current pen and paper-based hospital and patient records into electronic firms. The first challenge would be the sheer number of the old patient and hospital records stored in the department in their physical (i.e. pen and paper) form. If, for example, what we are dealing with is a medium sized tertiary hospital with more than 200 beds that deals with a high traffic of in and out-patients daily, the number of records that have to be converted all in all can easily number in thousands. Naturally, the larger the number of convertibles, the more time-consuming and complicated the entire process would be. Of course, if the department would only have to deal with one or even less than a hundred individual records and or documents, then that is an entirely different story. The second challenge would be the incompatibility of the record-keeping format used in storing the patient data in the former pen and paper-based system and the format of the new electronic medical record keeping system. One of the negative results of this is the omission of some pertinent data and the longer than usual time it would take to convert one document into its electronic form.
When it comes to the components that must be made mandatory in the form, the answer would be it depends. There are cases that require only a certain component of a medical record to be used while there are some that do not. Nonetheless, there are complex or even rare cases that require all components of a medical record to be used. In this case, it would really help to make the inclusion of all medical record components mandatory, even though some may be left blank sometimes, just so no data can be omitted when converting documents.
The last question that must be addressed would be whether the new electronic form would be simpler or be more labor intensive than its pen and paper-based counterpart. The answer to this question is that the new electronic form would be simpler. This is because of the fact that electronic forms of patient and hospital records are easier to store, they can be accessed wirelessly and with just a push of a few buttons, and more importantly, they can be easily backed up, unlike the pen and paper-based ones that are more prone to damage and degradation, and require a lot of work and resources to store and retrieve.

References

Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., et al. (2005). Can Electronic Medical Record Systems Transform Health Care. Health Affairs, 1103-1117.
McDonald, C. (n.d.). The barriers to Electronic Medical Record Systems and How to Overcome Them. Journal of the American Medical Informatics Association, 213-221.