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Electronic Medical Records

Written by Ana Canteli on February 24, 2023

The electronic medical record is a digital system used to capture, store, and share medical information about patients. Instead of classic paper records, healthcare providers use specialized software to record clinical information such as medical history, visit notes, test results, prescriptions, and other relevant data. Many health professionals use electronic medical records, including doctors, nurses, therapists, social workers, and other health care providers. Electronic medical records are also used by healthcare organizations, such as hospitals, clinics, and doctors' offices, to manage patient information and coordinate care and resources.

Electronic medical records allow medical staff to access patient information in real time from anywhere, improving patient care quality and reducing costs and medical errors.

Electronic medical records can be securely shared between different healthcare professionals; this helps improve care coordination and reduce duplication of tests, treatments, or waiting times.

Patients can also access their electronic medical records, allowing them to take greater control over their care and make informed decisions about their health.

Benefits of electronic medical records

Electronic medical records provide several advantages over traditional paper records. Some of the main benefits include the following:

• Accessibility: electronic medical records are available to healthcare professionals anytime and anywhere, meaning patient information can be accessed quickly and efficiently.
• Coordination of care: Electronic medical records allow different healthcare providers working with a patient to coordinate their care. It can help ensure proper treatment is provided correctly and prevent delivery failures.
• Reducing errors: Electronic medical records help to reduce the number of medical errors, as healthcare intermediaries have access to complete and up-to-date information about the patient's medical history, such as drug allergies, medications administered, previous treatments, etc.
• Improved efficiency: Electronic medical records can improve efficiency by allowing healthcare providers to enter and access patient information more quickly, accurately, and securely.
• Cost savings: Electronic medical records can save money in the long run by reducing the costs of storing, printing, and mailing paper medical records.
• Information security: Electronic medical records can be more secure than paper records. Security measures can be used to protect sensitive patient information that is impossible to implement in a physical format.

Who benefits from the electronic medical record?

Healthcare providers

Electronic medical records benefit any healthcare facility that wishes to improve the quality of care and increase efficiency in its work processes. Some specific situations where the use of an electronic medical records system can be particularly beneficial include:

• Healthcare facilities with a large volume of patients: electronic medical records can help healthcare providers manage large amounts of information more effectively and securely, improving the quality of care and reducing staff workload.
• Facilities that want to improve care coordination: Electronic medical records allow different healthcare providers working with a patient to coordinate their services. It can help ensure that the proper treatment is being provided and prevent medical errors.
• Facilities that want to improve efficiency and reduce costs: Implementing a medical records management system ensures secure and confident access to the information required by providers securely and confidentially. The investment in medical records management software and security measures is easily amortized by providing unified access to all intermediaries. In addition, the cost of storing, printing, and mailing paper medical records is minimized.
• Facilities that want to improve patient safety: electronic medical records can reduce the number of medical errors, as providers have access to the most up-to-date and complete information about a patient's medical history.

Medical staff

Electronic Medical Records (EMR) offer numerous advantages to healthcare professionals. Some of the most exciting benefits include the following:

• Instant access to information: With EMRs, healthcare professionals can access patient information at the click of a button from any device, anywhere. It allows them to make more accurate and timely treatment decisions.
• Coordination of care: EMRs enable better care coordination between professionals caring for patients. It can help improve the quality of patient care and reduce the possibility of errors.
• Improved efficiency: EMRs can help improve the efficiency of the healthcare facility by reducing the time spent managing medical documentation and eliminating the need to move paper records from one location to another. In addition, EMRs can help reduce time spent on administrative tasks, increasing efficiency and reducing the cost of low-value-added duties.
• Improved quality of care: EMRs allow medical staff to access a patient's complete medical history, which helps them make more informed and personalized treatment decisions. It can help improve the quality of care.

Patients

Electronic medical records provide benefits for healthcare providers and healthcare professionals and several advantages for patients. Some of these include:

• Access to information: patients can access their medical information more quickly and securely with electronic medical records. They can view their lab results, vaccination records, appointments, and clinic visit summaries.
• Improved quality of care: by accessing their up-to-date medical records, patients can make informed decisions about the next steps in their treatment.
• Time-saving: Electronic medical records can help save patients' time, as they can review their medical information and make appointments online, rather than having to call or physically travel to the medical center.
• Increased patient safety: electronic medical records help reduce medical errors. Healthcare professionals can access a patient's electronic health record in real-time and get up-to-date information on their condition. They can even use the electronic medical records management system to contact other professionals for consultations or information.

Setting up an electronic medical records management system

Electronic medical record management (EMR) involves a set of processes and practices to effectively manage electronic medical records in a healthcare facility. It may include the following:

• Data collection: all the most relevant patient data should be collected, including past medical information, laboratory test results, diagnoses, treatments, and previously prescribed medications.
• Data storage: The collected data should be stored according to the security policy of the electronic medical record system. It is essential to have a reliable and secure storage system that meets privacy and information security requirements.
• Data access and retrieval: Electronic medical records should be available to authorize medical personnel. In addition, a system must be in place for data retrieval in case of loss or system failure.
• Record maintenance and updating: Electronic medical records must be updated and available for real-time access. It is crucial that healthcare professionals update patient records regularly to ensure that the information is current and of high quality.
• Protecting privacy and data security: It is essential to have security and privacy measures in place to protect patients' electronic medical records. It may include implementing strong passwords, encrypting data, and monitoring access to records.
• Data analysis: Electronic medical records can also be used to analyze patient health and health facility performance data. This information can help improve the quality of medical services, patient care, or business decision-making.

Code of good practice in electronic medical record management

The following are some of the best practices in electronic medical record management:

1. Implement clear policies and procedures: it is essential to establish clear medical records management policies and procedures in the healthcare facility. These policies and procedures should be communicated to all staff and regularly reviewed and updated.
2. Train staff: All staff must be informed and trained in electronic medical record management, including data collection, storage, protection of privacy and data security, and retrieval of records in an emergency.
3. Use reliable security systems: Electronic medical records should be protected through the use of proven security systems, such as data encryption, access monitoring, and the use of strong passwords.
4. Conduct regular audits and reviews: It is essential to conduct regular audits and inspections of electronic medical records to ensure that established policies and procedures are followed, and that information is accurate and current.
5. Establish backup and recovery protocols: It is essential to have backup and recovery protocols in case of a loss or failure of EMR software. Electronic medical records should be backed up regularly and stored securely.
6. Provide limited access to records: Electronic medical records should be limited to authorized healthcare professionals. Establishing clear access and authorization protocols that protect medical records from unauthorized access is essential.
7. Respect privacy and confidentiality: It is essential to ensure that electronic medical records are managed with the utmost respect for the privacy and confidentiality of patients. All regulations and legal requirements regarding the privacy of information must be complied with.

OpenKM's electronic medical records management software provides the ideal technological environment to deliver state-of-the-art medical information management, facilitating the work of healthcare providers and providing a rapid return on investment for medical facilities and an enhanced patient experience.

If you want to learn how it does it, don't hesitate to ask us for a personalized online demo.