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Introduction To Electronic Medical Records

Introduction To Electronic Medical Records. Y. SINGH NELSON R. MANDELA SCHOOL OF MEDICINE DEPARTMENT OF TELEHEALTH SINGHY@UKZN.AC.ZA. Content licensed under Creative Commons Attribution-Share Alike 3.0 Unported. Learning Objectives. What a electronic medical records

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Introduction To Electronic Medical Records

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  1. Introduction To Electronic Medical Records Y. SINGH NELSON R. MANDELA SCHOOL OF MEDICINE DEPARTMENT OF TELEHEALTH SINGHY@UKZN.AC.ZA Content licensed under Creative Commons Attribution-Share Alike 3.0 Unported

  2. 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

  3. 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

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

  5. 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

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

  7. Comments by Clinicians Video One and Two

  8. 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

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

  10. BUT ….

  11. Problems • Technology: • Infrastructure • Training and expertise • Perception • Human Factor • May create discord • Change management

  12. 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 …

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

  14. Issues with CPR – Data entry • Data Capture • Data Input • Error prevention

  15. Issues with CPR – Data Display Bruce Slater

  16. Thank You

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