Electronic Medical Record
Electronic medical record (EMR) has impacted positively on patient care and the work lives of medical practitioners. Recently, medical knowledge, practices, guidelines, and processes have greatly changed. For instance, an evidence-based practice implemented by medical professionals has fundamentally improved the quality of care provided to patients. As a consequence, the lives of patients with chronic illnesses have been prolonged. The core reason why there is a significant success in the provision of care is the accurate data capture and storage through EMR. In essence, family physicians or patients cannot be able to memorize pertinent details about patients. Therefore, electronic data stored assist health workers to address the complex needs of patients. In addition, accurate and reliable data is required to establish and sustain relationships between professionals making up a multidisciplinary team. The electronic medical record has improved the quality of care by the support the decision-making process.
Definition and Examples
Effective and successfully run medical practice depends on efficient management of patient information. As such, medical practices have moved from manual paper records to electronic records. Jaakkimainen et al. (2013) define electronic medical record (EMR) as a collection of digital files or charts containing a medical history of a patient, medication, laboratory results, treatment plans, and billing information all centrally placed in a database. The database enhances information storage and access and establishes relationships between different data attributes of patients. The use of electronic medical records has considerably transformed medical records management because it incorporates the use of information technology. As a result, data stored about a patient can be promptly retrieved, amended, processed, and retrieved to support diagnosis and treatment of ailments based on historical data stored. Jaakkimainen et al. (2013) reveal that more than 75 percent of physicians are actively using electronic medical records. Physicians agree that the utilization of electronic medical records is integral to their medical practice. Today, there are numerous examples of EMR used by medical professionals and include eClinicalWorks, Allscripts, Cerner, NextGen, Kareo, Practice Fusion, and Epic among others. These numerous software applications centrally store patient information to assist medical practitioners to provide customized care.
The Working of Electronic Medical Records (EMR) Systems
The working of the EMR systems largely depends on the features the different software providers. Medical professionals may find it challenging to implement some EMRs while others may be able to use them depending on the target market. First, electronic medical records enhance security of patient data. It is reported in the news that computers of hospitals and clinics are prone to attacks by criminal hackers, holding patient data hostage in exchange for ransom (Manca, 2015). The EMR systems work by protecting and maintaining confidential and pertinent data on clients using multifaceted capabilities aligning to HIPAA privacy requirements. The EMR software systems have enhanced capabilities of strong encryption, allowing only authorized doctors, physicians, and nurses to access pertinent records of patients using laptops, tablets, and smartphones (Manca, 2015). Second, the EMR systems perform transcription using speech recognition capabilities. The transcription capability allows doctors to send recorded information through the system which automatically fills patient records displayed on the screen.
Third, EMR systems operate through the patient portal to give patients freedom and convenience in accessing personal data. The patient profile setup is simple and flexible allowing new patients to fill in details about their medical history, medication, and care intervention privately at the comfort of their homes or offices. In addition, the process of capturing data is faster and reliable eliminating data duplication problems. As a result, medical professionals do not have to spend much time filling in unnecessary details already keyed in by patients. Manca (2015) asserts that once data is already posted on the system, patients can easily view their lab reports and see reminders to take medication. Moreover, patients are able to raise queries and seek clarifications on unclear care intervention guidelines.
Fourth, EMR reports the daily routine of medical professionals to inform practitioners of planned staff meetings. Moreover, reporting capabilities allow administrators to report patients who are slow in paying their bills. Lastly, the EMR system works by necessitating electronic prescriptions in which patients know about their prescriptions before they exit medical facilities. The medications are often readily available by the time these patients reach the pharmacy. Per Manca (2015) electronic prescribing is fast and alleviates mistakes often made by pharmacists due to the inability to read unclear physician’s handwriting. Moreover, the electronic prescription empowers medical professionals to spot contradictions when prescribing numerous medications, and taking into account a patient’s use of herbal alternative remedies and supplements.
Challenges in Using an Electronic Medical Record
Hospitals and healthcare systems continue to face challenges regarding the implementation, maintenance, and upgrading of electronic medical records. Essentially, healthcare workers encounter challenges ranging from security to interoperability and clinical burnout. Per Brelsford et al. (2018), cybersecurity is a top challenge that clinicians face as they attempt to use EMR systems. Healthcare professionals have found it hard to secure the vast amount of data they collect and store despite the EMR systems having security structures within. In most medical organizations EMRs are procured, installed, and rolled out without proper training for the staff expected to use them. In return, the staff experience difficulties in securing data because at times they fail to fully utilize the security features embedded within the systems. In addition, lack of extensive knowledge has exposed most of the data and login credentials of workers to hackers and cybercriminals.
Interoperability is another challenge that health workers continue facing as they utilize EMR systems. Most healthcare professionals claim that most EMR are inflexible and systems do not communicate seamlessly with each other to gain a complete picture of the patient (Brelsford et al., 2018). The health workers claim that whether they are trying to accomplish meaningful utilization of the system or enhance care through its use, the developers must address the interoperability by enhancing system functionalities (Brelsford et al., 2018). As such, data need to be made available and transferred seamlessly from one system to another. Lastly, information overload and burnout is another challenge that health workers encounter. Brelsford et al. (2018) reveal that EMRs are excellent at collecting a vast amount of data, but the workflow is often overwhelming and confusing to health workers, leading to burnout. In effect, when workers are overwhelmed and burnout, their productivity reduces significantly.
Electronic Medical Record and Medical Error
Medical error is a nightmare no health worker wants to encounter. It is imperative to note that healthcare workers are humans and are prone to mistakes just like other professionals. In the United States, medical errors are ranked as the third factor contributing to deaths (Brelsford et al., 2018). Medication error is the most common error made by medical professionals. Brelsford et al. (2018) opine that patients often withhold important information leading to inaccurate diagnosis and prescription. The EMR systems play a fundamental role in identifying drug interactions or adverse reactions that lead to prescription errors. As a consequence, EMRs support accurate prescription detects suitable foods patients can consume, support appropriate prescription for patients with allergies, and administer correct dosage to clients. Moreover, EMR systems possess reconciliatory tools and options that reduce medication errors by more than 50 percent (Brelsford et al., 2018). Additionally, the split capabilities comprehensively list pre-admission medication and compare with adverse reactions associated with different patients.
The Electronic Medical Record and Research
Electronic medical records have been used by nurses in research to transform health care to improve safety, quality, and efficiencies by supporting decision-making. First, EMR is used in research because it provides quality medical data that is coded rather than textual. The coding used to capture data in the EMR system is essential in data mining, warehousing, and modeling critical in conducting evidence-based research (Coorevits et al., 2013). Consequently, EMR is linked to other systems like bio-data scanners and imaging devices increasing the availability of data usable in research. In essence, the data retrieved from EMR systems by researchers are free from errors since the data capture and storage in databases eliminate duplication that may affect the credibility of research findings. Second, EMRs are used in research because they contain a vast amount of structured and free-text data that can easily be manipulated and re-identified to be used in research without disclosing pertinent details of patients. Coorevits et al. (2013) reveal that research is anchored on ethical considerations, data privacy, and confidentiality. Therefore, researchers prefer to utilize EMR in research because the systems guarantee the confidentiality of data.
Third, electronic medical records work using algorithms relying on structured vocabulary searchers. Therefore, structured vocabulary searches are important to researchers who need to generate surplus information critical in identifying epidemics or any other object of evidence-based research. Fourth, the use of EMR in research enhances the application of findings in actual practice. Per Coorevits et al. (2013) research conducted through data retrieved from EMR databases have a time-lapse of 15 years before the findings are used in medical practice. Thus, the clinical decision support systems implemented in the EMR reduces the time lapse between the time research findings are acceptance and the actual implementation in evidence-based practice.
Patients and Electronic Medical Records
Patients have adapted greatly to the use of EMR systems in managing their pertinent data. Patients have favorable perceptions on the use of EMR in data as revealed by Kern et al. (2013) outlining that patients agree that EMR improves quality care. Patients have reported that EMR has increased the attention they receive from physicians due to increased communication and interaction. Moreover, EMR systems give provisions and capabilities to allow patients to set personal goals aimed at making patients stay healthy. Consequently, patients consider EMR systems as caring connections because it grants them unlimited access to their diagnosis, prescription, medication, and care intervention regardless of the locations (Kern et al., 2013). Through electronic medical records, patients are able to explore care in private practice, clinics, urgent care, and ambulatory facilities. As revealed by Kern et al. (2013), patient records can be accessed through myriad platforms and numerous tools like tablets, laptops, and smartphones.
Despite the benefits of electronic medical record systems, patients are experiencing several challenges as they attempt to access their data. The first challenge is the underutilization of patient portals as many patients only look for their data without using them to improve their overall health. Most of the functionalities have largely been unused by patients who claimed they have not been adequately trained. In other words, only a few patients use the data they access to make healthy choices as they face difficulties accessing advanced modules within the system. Secondly, patients find the security protocol of EMR to be ambiguous because clients have inadequate knowledge about their rights regarding the use of electronic data. The ambiguity has fundamentally derailed the access to numerous copies of data as documented under the Health Insurance Portability and Accountability Act (HIPAA) requirements. Finally, the patients encounter challenges of limited data interoperability as the data system may not adequately communicate with other external systems. Kern et al. (2013) exemplify that interoperability is crucial for patient access to health data, and without it patients are unable to access the data transmitted by providers to them. There is a need to improve interoperability to enhance client engagement and improve data access.
NextGen Electronic Medical Record
This system is suited for private medical practices. NextGen software essentially provides an integrated management solution offering specific patient content, a claim management module, and a simple patient portal. The application operates on tablets, windows and complies with HIPAA requirements (Kern et al., 2013). NextGen is beneficial to users because it allows the integration of the system with other patient management strategies. Moreover, the system enhances workflow and eliminates burnout problems because it is easy to use and the navigation panel is simple and understandable. Consequently, interoperability is made possible in NextGen making it easy for system users to retrieve data from other modules and external systems. The next Gen is associated with myriad problems that include the complexity of the system especially to lower-level users with no advanced knowledge of systems. Moreover, functionalities like claim processing modules are confusing to first-time users thereby posing challenges in processing information.
Kareo Clinical Electronic Medical Record
Unlike NextGen, Kareo is suited for both public and private medical practice and is used by thousands of people in the United States. Specifically, the software targets small medical practices and billing entities. Essentially, Kareo offers more functionality unlike NextGen because it schedules patients, confirms insurance arrangements, and manages delinquent accounts. Moreover, Kareo store client documents, and develop customized reports for decision-making. The system is beneficial to users because it is user-friendly and does not require rigorous training. As such, the templates produced are easily customizable based on the specific needs of patients and vendors. Moreover, the billing functions give users the ability to adapt through templates and micros essential in creating numerous documentation scenarios. Kareo is also associated with few problems including the lack of generic consent forms to authorize the processing of patient’s private data (Kern et al., 2013). Additionally, the patient module does not accommodate chart options other than demographic information displayed.
Indeed, electronic medical records have transformed the management of patient data to aid the process of decision-making and improve the quality of care offered to clients. Fundamentally, EMR systems improve patient outcomes, reduce medical errors, and improve communication and interaction between patients and service providers. However, patients and health workers experience challenges relating to insecurity posed by cybercriminals, interoperability challenges, and burnout among nurses. Likewise, patients encounter challenges relating to unutilized modules and interoperability problems. Notably, EMRs have enhanced research through the provision of accurate and structured data. Future research should evaluate the impacts of EMR in promoting equal access to medical services, especially among the uninsured population.
Brelsford, K., Spratt, S. & Beskow, L. (2018). Research use of electronic health records: patients’ perspectives on contact by researchers. Journal of the American Medical Informatics Association, 25(9), 1122–1129.
Coorevits, P., Sundgren, M., Klein, G., Bahr, A., Claerhout, B., Daniel, C. & Kalra, D. (2013). Electronic health records: new opportunities for clinical research. J Intern Med, 274(6), 547-560.
Jaakkimainen, R., Shultz, S. & Tu, K. (2013). Effects of implementing electronic medical records on primary care billings and payments: a before-after study. CMAJ Open, 1(3), 120-126.
Kern, L., Barrón, Y., Dhopeshwarkar, R., Edwards, A. & Kaushal, R. (2013). HITEC Investigators: Electronic health records and ambulatory quality of care. J Gen Intern Med, 28(4), 496–503.
Manca, D. (2015). Do electronic medical records improve quality of care? Yes. Canadian Family Physician, 61(10), 846–851.