Who said this and When?

“I am fain to sum up with an urgent appeal for adopting …

some uniform system of publishing the statistical records of
hospitals. There is a growing conviction that in all hospitals,
even in those which are best conducted, there is a great and
unnecessary waste of life … In attempting to arrive at the
truth, I have applied everywhere for information, but in
scarcely an instance have I been able to obtain hospital
records fit for any purposes of comparison …If wisely used,
these improved statistics would tell us more of the relative
value of particular operations and modes of treatment than
we have means of ascertaining at present.”
 Who and When

Florence Nightingale,
Notes on Hospitals,
London: Longman, Green,
Roberts, 1863
MEDICAL RECORDS
MEDICAL RECORDS

A medical record, health record, or medical chart is a

systematic documentation of a patient's
medical history and care. The term 'Medical record' is
used both for the physical folder for each individual
patient and for the body of information which
comprises the total of each patient's health history.
.
MEDICAL RECORDS

Medical records are intensely personal documents and

there are many ethical and legal issues surrounding
them such as the degree of third-party access and
appropriate storage and disposal
MEDICAL RECORDS

Although medical records are traditionally compiled and

stored by health care providers,
personal health records maintained by individual
patients have become more popular in recent years.
What is a health record?

A health record includes any information created by, or

on behalf of, a health professional in connection with
the care of a patient
Who are the Stakeholders

A medical record is property of the hospital, whereas the

data contained within the record is a privileged
communication in which patient has a vested interest.
If properly written, compiled, preserved and protected
from unauthorized inspection and disclosure, the
medical record benefits:
Patients
Physicians
Healthcare Institute
Research Team
National and International Health agencies
Who are the Stakeholders: indirect

Insurance companies
Workman compensation suits
Personal injury suits
Malpractice suits
Probate Cases
Notification of births and deaths
Criminal cases
Certification
Identification of patients
What format can a health record take?

A health record can cover a wide range of material:

Handwritten medical notes
Computerised records
Correspondence between health professionals
Laboratory reports
X-ray films and other imaging records
Photographs
Videos and other recordings
Audio recordings
Printouts from monitoring equipment
Record Lifecycle

Any record created by an individual, up to its disposal, is

a public record and subject to Information Requests

Close Record

Create Use Store Analyse Disposal

Flow of Medical Record

Central Admission Wards

Office

Medical Record
Department

1. Assembling After completion of

Records

2. Admission. &
Hospital statistics prepared
Discharge analysis
Monthly/Yearly

3. Storage Area Medical Record is filled for perusal

of Patients/claims/research
purposes.
Purpose

Provide continuity of care to individual patients.

Basis for planning patient care.

Documenting communication between the health care

provider and any other health professional contributing
to the patient's care.

Assisting in protecting the legal interest of the patient and

the health care providers responsible for the patient's
care.
.
Purpose

Documenting the care and services provided to the patient

Serve as a document to educate medical students/resident

physicians.

To provide data for internal hospital auditing and

quality assurance, and to provide data for medical
research.
SYSTEM OF MEDICAL RECORD

Medical Record of the patient stores the knowledge

concerning the patient and his care. It contains
sufficient data written in sequence of occurrence of
events to justify the diagnosis, treatment and
outcome.
In the modern age, Medical Record has its utility
and usefulness and is a very broad based indicator
of patients care.
SYSTEM OF MEDICAL RECORD

Traditionally, medical records have been written on paper

and kept in folders.
These folders are typically divided into useful sections,
with new information added to each section
chronologically as the patient experiences new
medical issues.
Active records are usually housed at the clinical site, but
older records (e.g., those of the deceased) are often
kept in separate facilities.
SYSTEM OF MEDICAL RECORD

The advent of electronic medical records has not only

changed the format of medical records but has
increased accessibility of files.
The use of an individual dossier style medical record,
where records are kept on each patient by name and
illness type originated at the Mayo Clinic out of a
desire to simplify patient tracking and to allow for
medical research.
Content of the medical record

Vary depending upon specialty and location

Patient's identification information

Informed consent forms
Patient's health history (what the patient tells)
Patient's medical examination findings (what the health-
care providers observe when the patient is examined).
Content of the medical record

Other information may include

Lab test results

Medications prescribed
Referrals ordered to health-care providers
Educational materials provided
Plans for further care
Patient instruction for self-care
Return visits
Billing information
Contents of Medical Record

Diagnosis and plan of treatment

Follow-up care
Telephone calls
Discharge summaries
Patient records from other physicians

20
The health record should be…

Available in the right place at the right time to support

effective patient/doctor contact and to provide
continuity of care

Availability of the complete record when needed is a key

determinant of the performance of Health Record
Services
Characteristics of full & accurate health records

 Authentic
 Reliable
 Complete & unaltered
 Processes & systems have integrity
 Useable
 Transferable
 Structured
Documentation

Key elements - accurate, complete, timely, legible

Source document - quality of the clinical record

Documentation errors - Main condition, other

diagnoses, operations
Documentation requirements

Do write:

Date and time of entries

Purpose of entry eg. admission note, planned review,
asked to see patient, end of shift report
History and examination findings
Assessment of current situation
Plan for what needs to happen now and later
Print name and sign, include position, contact details for
every entry
Use only approved abbreviations
Complete discharge summary and front sheet
Documentation requirements

Don’t write:

A repeat of clinical details previously written – this

wastes your’s and other’s time and wastes paper
Anything unpleasant, rude, or critical of either relatives,
patients or staff
Anything that is not true or does not reflect reality
Backdated entries or changes to existing entries
Documentation policy

 Need to ensure there is a documentation policy in

place so clinical staff know the requirements for
documentation and can be assessed against those
requirements

 See sample Guidelines for Medical Record and

Clinical documentation

 What are the requirements for clinical documentation

in your country? Are these written in a policy? Do
clinical staff know what they should be documenting?
Ways of improving documentation

1. record design - well structured, standard order,

complete, cover the scope of the care

2. forms design - elicit information needed for patient

care and coding, easy to use, legible, designed in
conjunction with health professionals who will use
them

3. education
clinicians - documentation is as much part of clinical
care as direct patient contact
management - channel resources and enthusiasm
into this area
Quality of medical record documentation

Timely and accurate documentation is associated with:

Improved quality of care

Seamless continuity of care
Enhanced ability to demonstrate equitable delivery of
service and improved outcomes
Streamlined work processes
Reduction in the duplication of work
Reliable data sources
Increased client, worker and payer satisfaction
Assessment of documentation quality

 Conduct a regular audit of documentation quality

 Use standard data collection form – can compare

results over time to determine improvements

 Consider the data items that must be presented in a

documentation quality report and the format in which
they should be recorded

 See example of documentation audit sheet

Process for a documentation audit

 Select a random sample of 5% of discharges in a

given month, or at least 10 records (whichever is the
higher number) should be audited

 Select records from a printout of the Medical Record

of all discharges in a month ordered by discharge
date. Select every 20th medical record number on
list for audit. If record selected is not available, the
next record on the list should be selected

 The audit relates to documentation within the

selected admission only
Rules for Charting

Clarity, thoroughness, and precision

Black or blue ink
First initial, last name and title
No empty space between chart entry and initial signature
Do not use ditto marks
Do not erase or obliterate entry
Draw a line through error, include correct information and
the word “correction” or “corr” next to entry
Rules for Charting

Patient’s name on every page

Use present tense
Never chart for another person
Describe events or behaviors
Be specific as you can
Date and initial any corrections
Leave no blank lines
Use standard abbreviations
Common Charting Mistakes to Avoid

Failure to record pertinent health or drug information

Failing to record nursing actions
Failing to record that medications have been given
Recording on the wrong chart
Failing to document a discontinued medication
Failing to record drug reactions or changes in the
patient’s condition
Transcribing orders improperly or transcribing improper
orders
Source-Oriented Medical Records

Traditional or conventional method used

Chronological set of notes for each visit
Is difficult to follow or track specific problems
May be handwritten or transcribed in the chart

34
Problem Oriented Medical Records
Problem list
Diagnostic and treatment
plan
Progress notes
Medical records department

Functions as a part of central information services

Medical records committee

Medical records officer
assistant Medical record officer
Medical record technicians
Attendants/messengers/admission clerks
Organization Chart by functions
Organization chart by staff
Staff requirement
Department
layout
Functions of medical records department

Creation and Control of forms, registers

Daily receipt of case sheets pertaining to discharge from
various wards, there checking and assembly.
Daily compilation of Hospital census report.
Maintains & retrieval of records for patient care and
research study.
Completion and Processing of Hospital statistics and
preparation on different periodical reports on
morbidity and mortality.
Online registration of vital events of Birth & Death
Issuing Birth & Death certificated up to one year.
Functions of medical records department

Dealing with Medico Legal records and attending the courts

on summary.
Arrangement & Supervision of enquiry and admission
office.
Arrangement & Supervision of OPD registration
Management of disability boards.
Management of Medical Examination
Management of Mortality Review Committee Meetings
(Twice month)
Assistance to Hospital Administration in various matters.
International Coding of Diseases

ICD-10
Introduction

For clinical coding to be as valuable as possible it is

critical the coder has:

 access to a comprehensive and accurate medical

record,
 the skills to extract all pertinent data for coding,
 access to clinicians to ask questions and seek
clarification
Sources of clinical data for coding

Morbidity coding is usually performed after the patient

has left the hospital

Information to be coded is abstracted from the whole

medical record

The coding process has two parts:

analysis of the medical record
allocation of correct codes
Responsibilities

Coders
reviewing the entire record
verifying the record contains appropriate
documentation
coding specifically and accurately the conditions or
diagnoses treated or affecting a patient’s care
referring the record to clinicians for clarification

Clinicians
recording accurate and complete clinical
documentation in the medical record
recording all diagnoses on the front summary sheet
identifying the main condition
Abstraction of Relevant Data from Medical Record

1. Read the discharge summary or other correspondence

2. Compare any diagnosis in the discharge summary/letter
with that recorded as admission or provisional diagnosis
and with that recorded on the front sheet
3. Read the history and physical examination
4. Read the front sheet of the relevant admission
5. Identify relevant procedures
6. Review the entire record
7. Clarify information with the clinician if necessary
When to consult with the Medical Officer

If conflicting, incomplete or ambiguous information is

found or if documentation is unclear
Check with the attending medical officer,
the medical officer who filled in the front sheet
or the radiologist or pathologist

Coding should be a cooperative and collaborative effort

between the clinician and the coder
What to code?

Main condition or principal diagnosis

+/- other or secondary conditions

+/- procedures, operations and interventions

 Selecting the Main Condition or Main Diagnosis

Consider those conditions which:

caused the patient to be admitted
were treated and/or investigated during the acute
admission
affected the treatment given and/or the length of stay
developed during the admission

The main diagnosis can then be selected from these

conditions
WHO definition of main diagnosis or main condition

…the diagnosis established at the end of the episode of

care to be the condition primarily responsible for the
patient receiving treatment or being investigated…
that condition that is determined to have been
mainly responsible for the episode of health care...

(ICD-10, volume 2, 4.4)

Secondary diagnosis / Other condition

❧ a diagnosis that either co-exists with the main

diagnosis at the time of admission, or which appears
during the episode of care

❧ complications and comorbidities

What is a comorbidity?

A disease that accompanies the main diagnosis and

requires treatment and additional care, in addition to
the treatment provided for the condition for which the
patient was admitted
 What is a complication?

A disease that appears during the episode of care, due to

a pre-existing condition or arising as a result of the
care received by the patient
Problems with determining the main diagnosis

 absence of a clear-cut main diagnosis

 minor condition recorded as main diagnosis
 diagnosis recorded in general or ill-defined terms
 uncertainty of diagnosis
 symptoms or signs listed as the main diagnosis
 no diagnosis recorded
What is accurate coding?

 each diagnosis must be assigned its correct code

(or codes)
 Codes should be as complete as possible
 all diagnoses affecting the care of the patient and
procedures performed during the episode of care
should be assigned codes
 codes must be sequenced correctly with the main
diagnosis listed first
 morbidity coding rules in volume 2 of ICD-10 should
be followed
To ensure accurate coding:

Coders should be familiar:

with anatomy and physiology of the human body
with medical terminology so that disease
descriptions can be interpreted into ICD
language
with disease processes and medical practice to be
able to understand aetiology, pathology,
symptoms, signs, diagnostic procedures, etc.
To ensure accurate coding:

Coders should also have:

an understanding of the content of the medical record

experience with the actual medical records so specific
details can be located
detailed knowledge of the coding system being used
an understanding of data reporting requirements
Quality Assurance in Morbidity Data Collection

Increasing use of morbidity data leads to an increasing

concern for the reliability of data

Sources of error in MR information systems:

documentation of the patient’s care and condition
during the episode in hospital
coding the information in the medical record
processing the coded information
Coding accuracy

Three dimensions of coding accuracy:

accuracy and completeness of individual codes

accuracy of the totality of codes to ensure they reflect
all diagnoses treated; and
accuracy in the sequence in which the codes are
recorded, particularly in selection of the main
condition
Common sources of coding errors:
Clerical
careless mistakes, transposing numbers
Judgmental
wrong subjective decisions taken
Knowledge
mistakes due to lack of coder knowledge
Systematic
errors in the process of coding or problems with the
environment in which coders work
Documentation
incomplete, inaccurate, ambiguous, conflicting
illegible
What affects coding quality?

Errors in the choice of code

Lack of feedback
Casemix – number and type of cases to be coded
Use of coding conventions and coding rules
Lack of clarity in coding books
Changes in coding practice
 What affects coding quality?

Documentation
Incomplete medical records
Availability of records
Coder/ clinician communication
Data entry
System edits
Forms design
What affects coding quality?

Workload
Education
Human resources
Environment
The individual
Reference material
Coder/Clinician Communication is important

Team approach to achieve complete and accurate

documentation
Clinician’s responsibility to record accurate diagnoses
and procedures and document fully the episode of
care
Coder’s responsibility to review and use
documentation; use standard definitions, use their
skill and knowledge of the current coding system
Why has communication traditionally been lacking?

 lack of understanding of coding as a process and of

the importance of coded data
 clinicians do not feel a sense of ownership of the
classification system or the fact that the coded data
reflect their work
 coders feel intimidated about asking questions,
seeking advice or asking about clinical issues
Ways of improving communication

 encourage clinicians to attend coding meetings in

the clinical coding/medical record department
 request coders attend clinician meetings conducted
by each clinical specialty
 organise coding service to allow coders to
specialise
 clinician involvement in the development of coding
guidelines
 education for clinicians and coders
Five steps for quality control of coding:

 establishment of objective criteria for coding quality

 measurement of performance
 analysis of problems identified
 action taken to correct identified problems
 review of performance after corrective action
Link to ICD-9

C:\Program
Files\Skyscape\Desktop\ICD-9-CM\ICD-9-CM.exe
Auditing

To inspect and verify

To determine the degree of accuracy in ICD

coding based on coding rules and coding
conventions
Audit principles

Coder A (original coder)

Coder B (auditor)

Coder C (independent adjudicator)

Sample selection

Period of audit

Audit sample
Random sample
Target sample
Sample selection

Random
Representative of morbidity database
Suitable for benchmarking
Only some records will have errors
Sample size recommended 5%
Random number generator or table
Sample selection

Target
Defined by coder-in-charge or auditor
Cases selected because of known or suspected
errors or difficult cases or because a new coder
has started work
Only some records will have errors
Retrieving and preparing clinical records

 Retrieve original record

 Temporarily remove or obscure coded data

Recoding process

Coder B
Recodes each record
Assigns error categories if errors found – tries to
determine what has caused the error

If there is a dispute, Coder C

Recodes each record
Assigns error categories
Coder C recoding

 Recodes record ‘blind’

 Discusses code differences with Coder A and

Coder B

 Make final decision about correct codes

 Assign errors to error categories

Examine and analyse results

Need to develop a form for reporting of results

Scoring Tool form
Summary Data form

The summary data forms the basis for a report about

coding quality and can be used to compare data at
different time periods.
Questions to ask when reviewing coding:

Is the main diagnosis correctly identified?

Are all secondary diagnoses coded?
Are all diagnoses coded?
Are all diagnoses and procedures coded correctly?
Have the codes been transcribed or data entered
correctly?
Coder competency is influenced by:

Knowledge
Skill
Attitude
Behaviour
Experience
Ways of improving coder competency:

Training (initial education and training)

Continuing education (ongoing education)
Reference materials
Coder peer support
Recognition of competence
THE LEGAL ASPECTS OF MEDICAL CONFIDENTIALITY
LAW

A duty of confidence arises when confidential

information comes to the knowledge of a person in
circumstances where he has notice, or is held to
have agreed, that the information is confidential, with
the effect that it would be just in all the
circumstances that he should be precluded from
disclosing the information to others.

1 OF 2
THE EXCEPTIONS

WHERE THE PATIENT GIVES CONSENT

WHERE INFORMATION IS SHARED WITH HEALTHCARE

PERSONNEL CARING FOR PATIENT

1 OF 4
THE EXCEPTIONS

WHERE, ON MEDICAL GROUNDS, IT IS UNDESIRABLE TO

SEEK PATIENT’S CONSENT, MAY DISCLOSE
INFORMATION TO FAMILY OR CLOSE RELATIVE

WHERE DISCLOSURE TO THIRD PARTY WOULD BE IN THE

BEST INTEREST OF THE PATIENT [EXCEPTIONAL
CIRCUMSTANCES ONLY]

2 OF 4
THE EXCEPTIONS

WHERE IT IS IN THE PUBLIC INTEREST [EXCEPTIONAL

CIRCUMSTANCES ONLY]

WHERE IT IS NECESSARY FOR THE DOCTOR’S SELF-

PROTECTION OR DEFENCE

3 OF 4
THE EXCEPTIONS

WHERE A STATUTE REQUIRES DISCLOSURE

WHERE A COURT ORDERS DISCLOSURE

WHERE IT IS NECESSARY FOR PURPOSES OF APPROVED

MEDICAL RESEARCH

4 OF 4
THE PATIENT’S BEST INTEREST

DISCLOSURE TO FAMILY MEMBER OR CLOSE RELATIVE

ALLOWED WHERE PATIENT INCAPABLE OF MAKING
INFORMED DECISIONS ABOUT HIS OR HER OWN
TREATMENT

1 OF 4
THE PATIENT’S BEST INTEREST

PATIENT IS UNCONSCIOUS, EG. COMA

PATIENT IS TOO ILL

PATIENT IS A YOUNG CHILD

PATIENT IS AN INCOMPETENT ADULT, EG.

MENTAL ILLNESS OR SENILITY

2 OF 4
THE PATIENT’S BEST INTEREST

DISCLOSURE TO FAMILY MEMBER OR CLOSE RELATIVE IS

ALSO ALLOWED WHERE IT IS UNDESIRABLE IN THE
INTEREST OF PATIENT’S HEALTH, TO DISCLOSE
INFORMATION TO HIM DIRECTLY

3 OF 4
THE PATIENT’S BEST INTEREST

WHERE PATIENT IS IN A VULNERABLE STATE

OF MENTAL HEALTH, EG. SUICICAL,
DEPRESSION

IN SUCH CIRCUMSTANCES, DISCLOSURE TO

PATIENT MAY PUT HIS LIFE/HEALTH OR
OTHERS AT RISK

4 OF 4
PARENT VS CHILD

PARENTAL RIGHT DIMINISH AS THE CHILD ACQUIRES THE

ABILITY TO MAKE DECISIONS

PACE OF DEVELOPMENT WILL VARY FROM CHILD TO CHILD

PARENTAL RIGHT WILL TERMINATE WHEN THE CHILD HAS

SUFFICIENT UNDERSTANDING AND INTELLIGENCE
PARENT VS CHILD

DOCTOR MUST ACT IN PATIENT’S BEST INTEREST AND

MUST SATISFY HIMSELF THAT PATIENT HAS
SUFFICIENTLY MATURE UNDERSTANDING

DOCTOR MUST EXERCISE PROFESSIONAL JUDGMENT

DOCTOR MUST RESPECT PATIENT’S CONFIDENTIALITY IF

PATIENT SATIFIES THE TEST OF MATURITY
THE PUBLIC INTEREST

DISCLOSURE MAY BE DESIRABLE AND APPROPRIATE TO

PROTECT THE PUBLIC WHERE THE DOCTOR HAS REASON
TO BELIEVE THAT PATIENT’S MEDICAL CONDITION PUTS
OTHERS AT RISK
THE PUBLIC INTEREST

WHERE A CRIME HAS BEEN COMMITTED

WHERE A CRIME IS LIKELY TO BE COMMITTED

THE PUBLIC INTEREST

WHERE THE PATIENT IS A CARRIER OF AN

COMMUNICABLE DISEASE

WHERE THE PATIENT HAS AN ILLNESS WHICH

MAY AFFECT MOTOR FUNCTIONS AND LEAD
TO LOSS OF SELF-CONTROL
THE PUBLIC INTEREST

THESE CIRCUMSTANCES ARE NOT ABSOLUTE

THE PUBLIC INTEREST MUST BE BALANCED AGAINST THE

PATIENT’S RIGHT TO CONFIDENTIALITY

ONLY WHERE THE PUBLIC INTEREST IS OVERWHELMING CAN

CONFIDENTIAL INFORMATION BE DISCLOSED

DISCLOSURE CAN ONLY BE MADE TO THE APPROPRIATE

AUTHORITY AND NOT TO THE PUBLIC AT LARGE
COMPULSION BY COURT ORDER

MUST COMPLY STRICTLY WITH COURT ORDER

FAILURE TO COMPLY MAY LEAD TO CONTEMPT

PROCEEDINGS

NO PRIVILEGE FROM DISCLOSURE OF CONFIDENTIAL

INFORMATION IN COURT PROCEEDINGS
SELF-PROTECTION

IN DISCIPLINARY PROCEEDINGS, DOCTOR MAY DISCLOSE

CONFIDENTIAL INFORMATION ABOUT A PATIENT TO
DEFEND HIMSELF AGAINST PATIENT’S COMPLAINT

PATIENT WHO MAKES COMPLAINT IS PRESUMED TO HAVE

WAIVED CONFIDENTIALITY
CONSEQUENCES OF BREACH OF CONFIDENCE

ACTION BROUGHT BY PATIENT FOR BREACH OF

CONFIDENCE

POSSIBLE REMEDIES IN CIVIL PROCEEDINGS

INJUNCTION TO RESTRAIN BREACH/ FUTURE BREACHES

DAMAGES IN LIEU OF INJUNCTION

CONSEQUENCES OF BREACH OF CONFIDENCE

DISCIPLINARY PROCEEDINGS - COMPLAINT TO SMC

PROFESSIONAL MISCONDUCT IF DOCTOR DISCLOSES

CONFIDENTIAL INFORMATION WITHOUT PATIENT’S
CONSENT, OR WITHOUT JUST CAUSE
CONCLUSION

IMPORTANCE OF DUTY OF CONFIDENCE

DISCLOSURE ONLY ALLOWED WHEN ONE OF THE

RECOGNISED EXCEPTIONS APPLIES

SERIOUS CONSEQUENCES IF DUTY OF CONFIDENCE IS

BREACHED WITHOUT JUST CAUSE
Authorization for release of information
Record Maintenance

Control record movement and location

Storage areas should be clean and tidy

Stores should be secure

Secondary storage for non-current records

Contingency/Business Continuity Plans

Scanning

Scanning paper records can reduce storage requirements

However:

Costs of initial conversion

Consult with The National Archives

Protect the evidential value

Retention and Disposal Arrangements

All organisations should have Record Retention and Disposal

policies to ensure records are annually selected for:

• Secondary storage (eg off-site or scanned etc)

• Permanent archival preservation
• Destruction
Record Destruction

Records must be destroyed in a secure environment

Contractors must abide by Confidentiality Agreements

Maintain a register of the destruction of records

 All The Reasons You Should
Incorporate EMR into Your Practice
“Change requires a coalition of people who, through
position, expertise, reputations, and relationships,
have the power to make change happen.”

John P. Kotter in “Leading Change”

Use of Electronic Medical Records

Sweden

Netherlands

Denmark

United Kingdom

Finland

Austria

Germany

Belgium

Italy

Luxembourg

Ireland

Greece

United States

Spain

France

Portugal

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 1

A Reality Check

Our healthcare system is fragmented….care is delivered by a variety of

independent physicians, hospitals and other providers

Clinicians often take care of us without knowing previous treatments

and by whom…which can lead to treatments that are redundant,
ineffective or dangerous

Vital data sit in paper-based records not easily accessed or combined

into a integrated form to present a clear and complete picture of our
care

Physicians spend an estimated 20-30% of their time searching for and

organizing information
Access to Patient Data

Instant Access to Patient Data

24/7 Access to Patient Data
Multiple Access to the Same Chart
An end to “lost” charts
No Waiting for Transcription to Come Back
Precise Documentation

No more illegible handwriting

No loose paper
Documentation neat and orderly
Ability to update medications and problems lists at each
visit
Exportation of Orders
Importation of Test Results
Better Care Management

Ability to Track Pending Orders

Automated Reminders
Ability to Print Patient Educational Materials
Ability to Print or Fax Progress Notes referring MD
immediately upon request
Instant Clinical Alerts
Efficient Prescribing

E-Scribing
No more calls from pharmacy “can’t read the doctor’s
writing”
Ability to fax Rx refills directly to pharmacy, no more calls
Electronic drug interaction alerts
Ability to incorporate insurance formularies into EMR
system
Instant Allergy Alerts
Enhances Productivity

Instant Messaging
Electronic Work Lists
Less Time Chasing Charts, More Time With
Patient/Patient Care
Instant Information
Patient Education Materials at Finger Tips
Why an Electronic Medical Record?

Majority of errors do not result from individual recklessness,

but from flaws in health system organization (or lack of
organization)

Paper records have at least 4 weaknesses:

Lack of standardization in content
Lack of standardization in format
Incompleteness
Inaccuracies

Source: Committee on Improving the Patient Record, Institute of Medicine

Paper Record Versus EMR

A patient’s age is not included in the medical record

10% of the time
A diagnosis is not recorded in the patient’s record 40%
of the time.
Physicians, while taking a medical history, fail to note
the chief complaint in the patient’s record 27% of
the time.
Paper Record Versus EMR

Physicians spend up to 38% of their time writing up patient charts.

Nurses spend up to 50% of their time writing up charts.

Medical records are misplaced or missing in 30% of patient visits.

The average patient visit generates 13 pieces of paper.

The average office spends $10 per visit to track and file paper records

The average patient record weighs 1.5 lbs.

Source: Committee on Improving the Patient Record, Institute of Medicine

Patient Benefits

Clinicians receiving computerized patient symptom assessments prior to a patient visit

addressed 51% of their patients symptoms, compared with only 19% of those not
receiving assessments

63% of consumers in a February 2004 survey agreed it would be “very valuable” to have
their complete medical history stored in one computer file that can be accessed
anywhere in the hospital

Foundation for Accountability Survey found that Consumers believed that having health
information online would:
Clarify doctor instructions – 71%
Prevent medical mistakes – 65%
Change the way they manage their health – 60%
Improve quality of care – 54%

A Harris consumer interactive poll found that:

80% want personalized medical information on-line from their physicians
69% want on-line charts fir tracking chronic conditions
83% want to receive their lab tests on-line
Summary of EMR Benefits

Chart Pull
Transcription Savings Decreased Billing
Savings Errors

5%
5% 13%
Adverse Drug
Events Prevention Increased Billing
Capture
15% 14%

Radiology
Savings
Drug Savings
15%
Lab Savings
29%
4%

Source: Partners Health Care experience based on 2500 patients and providers. “Cost and Benefit Analysis for electronic medical
records in primary care.” The American Journal of Medicine 2003;114:397-403
EMR Functionality

Best Practice guidelines

Clinical Decision Support, based on national guidelines
e-Rx, with alerts and formulary compliance by patient’s specific
health plan
Integration with lab orders and results
Integration with radiology orders, reports and the any new Picture
Achieving Communication (PAC) System or viewing of digital
films.
Patient Summary screens that summarize patient’s clinical condition,
including e-Rx, allergies, procedures, hospitalizations, chief
complaints, prior visits, allergies, family history, social history,
etc.
Educational materials in multi languages, that is, automatically
customized to the patient’s specific clinical and social needs.
EMR Functionality

Auto interface to hospital and ambulatory dictations

Web-Based Personal Health Records (PHRs), so that family can
review selected materials that physicians elect to provide
electronically o Health maintenance recording and tracking for
outcomes measurement
Integration with document imaging and workflow management
Clinical messaging between physicians and the staff
Clinical messaging between the physicians and the patient’s families
for selected activities
EMR Functionality

Recording and tracking of telephone messages

Electronic Rx refills
Order tracking and alerting if a test result has not been completed
within a specific period of time
Template-driven clinical charting, to ensure that chart clinical
information is complete and interoperable between specialists
Access anywhere, at anytime, on any device
Synchronization of records

When care is provided at two different facilities, it may be difficult to

update records at both locations in a co-ordinated fashion.
Two models have been used to satisfy this problem: a
centralized data server solution, and a peer-to-peer
file synchronization program (as has been developed for other
peer-to-peer networks).
Synchronization programs for distributed storage models, however,
are only useful once record standardization has occurred.
Merging of already existing public healthcare databases is a common
software challenge. The ability of electronic health record
systems to provide this function is a key benefit and can improve
healthcare delivery
Customization

Each healthcare environment functions differently, often in significant

ways. It is difficult to create a "one-size-fits-all" EHR system.
An ideal EHR system will have record standardization but interfaces
that can be customized to each provider environment. Modularity
in an EHR system facilitates this. Many EHR companies employ
vendors to provide customization.
This customization can often be done so that a physician's input
interface closely mimics previously utilized paper forms.
Customization

At the same time they reported negative effects in communication,

increased overtime, and missing records when a non-customized
EMR system was utilized.[65] Customizing the software when it
is released yields the highest benefits because it is adapted for
the users and tailored to workflows specific to the institution.
Customization can have its disadvantages. There is, of course,
higher costs involved to implementation of a customized system
initially. More time must be spent by both the implementation
team and the healthcare provider to understand the workflow
needs.
Development and maintenance of these interfaces and
customizations can also lead to higher software implementation
and maintenance costs.
These hurdles make customizations that can be made publicly
Disadvantages of electronic medical records

While EHRs may save the "health system" money,

physicians, those who buy the systems, may not benefit
financially.

Some physicians are skeptical of such published cost-

savings claims, however. They believe the data is skewed
by vendors and by others who have a stake in the success
of EHR implementation. Many are resistant to invest in a
system which they are not confident that it will give them
a return on their investment.
Disadvantages of electronic medical records

Physicians do tend to see at least short-term decreases

in productivity as they implement an EHR. They spend
more time entering data into an empty EHR than they
used to spend updating a paper chart with a simple
dictation.

Studies also call into question whether, in real life, EHRs

improve quality.
 Patient register and appointment planner

Add Clinical data

Add Lab records and medical images

Enable Web based upload and access

Pool related data from a group

Use pooled data for retrospective study and plan prospective study
The Incremental EMR