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CO-ORDINATION: The average patient today has 11.2 different medical records in existence. These numerous records are difficult to coordinate, and often are not shared between different providers treating a patient. Even when they are, providers with different specialties may not be able to easily interpret one another’s notations. The electronic health record helps integrate clinical viewpoints and facilitates shared care by using a reference terminology. It recognizes the different forms of expression used by the various clinical specialists for identical concepts.

ORGANISATION: Every provider has a different method of recording information, and what seems clear to one may be haphazard to another. Critical data may be unavailable when needed – lost in the clutter, on the wrong chart, in the wrong section of a chart, or not charted at all. The electronic health record provides a standard method for recording patient information that is easily accessible and retrievable. It brings a new level of quality and connectivity to the record.

PROLIFERATION: The number of forms used to record and control health care continues to increase by leaps and bounds: in fact, one study examining nursing forms found 386 forms in simultaneous use in one small hospital. The electronic health record drastically reduces paperwork by aggregating the majority of information currently contained in paper forms into one electronic source. With ER solutions, data can be captured once and reused endlessly for documentation, decision support and statistical reporting.

PATIENT INPUT: With numerous paper forms, a patient’s record is not easily portable and does not automatically follow when the patient moves or changes providers. As a result, patients must repeat the same information over and over again and may inadvertently leave out vital information. Patients provide information once and it can be made available throughout their lifetime to any provider of their choice. When information is computer coded, any provider of care can immediately apply and understand the information – even if using a completely different language.

ACCESSIBILITY: Paper records can only be at one place at one time, meaning that providers at different locations cannot easily access and review a patient’s records and medical history. The electronic health record can be accessed and viewed by providers who work across the street from one another, across the country or even across the world, ensuring that the most up-do-date information is always available at the point of care.

LINKAGE: In paper records, there is no automatic means of linking or retrieving practice enhancers such as clinical alerts, health education tools, medical literature and knowledge databases. The electronic health record can link clinical documentation to e-coded literature references, education materials, treatment guidelines and other practice enhancers.

DATA AGGREGATION: For population-based studies and outcomes, abstracting medical records adds unnecessary administrative costs to the health care system. With well-coded electronic health records, the promise of administrative simplification and evidence-based medicine on a global scale can be realized.

THE NEXT STAGE

In recent years, it has been demonstrated that for CPR to be more complete, images and signals need to be added. The word Multimedia Patient Records was coined to describe this. It will require the development and installation of one integrates solution or the upgrading of systems by adding new software and introducing the new technology. Also expertise in networking, communication and integration is required.

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