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Electronic health record EHR systems record health-related information on an individual so that it can be consulted by clinicians or staff for patient care. Formal evaluations of EHR in developing countries have shown successful implementation.

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The Mosoriot Medical Record System evaluation in Kenya showed improved staff productivity and reduced patient wait times Rotich et al. Laboratory information management systems are used to report results to administrators and healthcare personnel. These systems can potentially decrease the time to communicate results, reduce errors, and improve the productivity of a laboratory.

These systems have also been deployed in low-resource settings, such as a system in Peru Blaya et al. Pharmacy information systems can be used to order, dispense, or track medications or medication orders, including computerized order entry systems. A systematic review Robertson et al. These systems can also be used to determine if medication is being prescribed according to clinical guideline recommendations.

This study noted that without good communication between pharmacists and physicians, the full benefits of this type of system may not be realized. Developing countries are also deploying these systems. Training and communication processes are critical issues in the successful implementation of these systems. Electronic health records EHR are increasingly used in all healthcare settings. Dental practice management software integrates all aspects of the dental practice into a single digital file containing all of the types of entries that were commonly found in written patient records.

There are many significant benefits to use of an EHR system. Laboratory test results, photographs, radiographs, and other images, as well as all consultation and progress notes, are all housed within a single record. From a legal perspective, the EHR has some clear advantages because the record is optimally organized and the notes are more legible. Progress notes are generally more structured, with fewer recording errors and missed components. In addition, electronic systems encourage timely completion of notes, and the availability of rapid information retrieval promotes more efficient delivery of patient care.

Additional quality assurance benefits include the following:. On the other hand, the EHR complicates some processes that were once relatively simple. Although the physical act of entering the note may be delegated, the dentist remains responsible for ensuring that a complete and accurate note is entered. If changes are made to an electronic progress note, it is imperative that the date of the original entry and the original text be recorded and archived. Although there is no relevant dental case law as yet, it is clear from business and criminal cases in other areas that forgeries and alterations to electronic documents remain detectable.

Electronic health records EHR , sometimes also referred to as electronic medical records EMR , are rapidly replacing paper charts in the hospital setting. One of the advantages of EHR is easy availability of healthcare information to all providers, including sharing of health records with patients through web-based secure access. Integrated database analysis allows graphing health trends, reconciling medications, and even flagging of potentially negative pharmacological interactions. In addition, there is increased safety because an EHR can be backed up remotely, which provides redundancy in case of catastrophic loss of the primary record.

However, in addition to being a retainer of information, a paper chart has additional functions which may not be immediately obvious but need to be integrated into the EHR for a successful transition. The following list includes a sample of paper chart functions that need to be transferred to EHR:. Charts contain information in an organized manner. The EHR must be able to categorize information in a systematic manner such that the care team can easily find and retrieve important information, especially from scanned documents such as pdf files.

Search functions should include the ability to search document titles and file contents. The ability to view multiple documents simultaneously is highly desirable. The paper chart contains written treatment records, which include checkboxes or signature lines for completed second check, weekly chart check, MD signature, imaging protocol and imaging review, and use of accessories such as bolus. These items provide an easy visual check on performance of quality control processes according to the policies and procedures implemented in the department.

Transferring these checks to the EHR system can be challenging, because those paper chart functions were not obvious for the initial software designs in EHR e.

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Another example is the ordering and recording of the different bolus regimens: One way to address this is to schedule bolus and no bolus treatments into the treatment calendar of the EHR. A handover of a paper chart from one member of a patient care team to another initiates a workflow task e.

Most EHR systems have several tools to communicate workflow tasks; in addition, tools outside the EHR such as pages, emails, or texts can be used. It is recommended that the department standardize the workflow task method used at each step in the patient treatment workflow to avoid delays in communicating tasks.

Electronic Health Record

Task cascading, which automatically notifies the next step in the workflow upon completion of a task, is available in some EHRs. A paper chart is also used as a tool to communicate essential information among caregivers e. As for workflow tasks, EHR systems may contain multiple possible channels of communication among caregivers. This can be done by having a proper infrastructure in place to manage all these data so that the data can be converted or translated into knowledge, which can then be used to make a decision [ 1 ]. A substantial amount of data is able to produce large-scale analysis such as on the outcomes, trends etc.

Medical errors can occur with regards to incorrect diagnosis, wrong prescription of medication, inaccurate interpretation of laboratory results, and incorrect information generated from medical or laboratory equipment. By having health informatics, these errors can be minimized. Although the application of ICT can reduce medication and communication related errors via the use of Electronic Health Records EHR , it was less convincing in terms of diagnostic and technological related errors. In a study by Rajasekar on the implementation of IT in the healthcare system in the United States, the findings have not shown much significant achievements although the rate of medical errors has been reduced [ 3 ].

There is also a need to link the information on medical care provided by the healthcare providers and medical care received by the patients with insurance providers so that the medical treatment and fee reimbursement can be done promptly. All the documents required by the insurance provider can be made available online by both the healthcare providers and patients so that the insurance providers are able to access the documents without any delay. This can pose a risk as the medical records can get lost, be stolen or destroyed by fire. To avoid this, electronic health records EHR systems is the best solution since the data can be safely stored and encrypted.

The most common issue that arises in any information system is the system compatibility. Due to incompatibility of various systems, there is a need to develop a new system which can integrate the existing system. It is difficult to develop a new system and neither it is possible to integrate various systems because this involves various locations and also different operating systems. To develop a good information system and EHR; factors such as types of data number, text, digital images, videos etc.

A case study by Piliouras et al. The information technology requirement does not affect the integration of EHR into healthcare rather it is human, organizational and managerial issues that can have an effect [ 5 ]. There is a limited understanding of human information behavior as noted by Spink and Cole [ 8 ]. The health information system must consider individual needs based on the human behavioral models in health informatics [ 5 ].

Electronic Health Record - an overview | ScienceDirect Topics

For example, some patients may require certain information at a particular time that is, the patients may want to know only the diagnosis and not the rest of the information on the disease [ 9 ] such as risk factors of the disease, treatment etc. The information from various sources needs to be filtered so that quality and accurate information can be provided. Berner and Moss have noted that although the health information may be available in the health informatics, healthcare providers may not be able to use this information effectively [ 10 ].

It is vital to understand the process of data mining, data analysis and interpretation of findings when it comes to healthcare [ 5 ]. Sometimes the findings may be statistically significant but may not necessarily be clinically important [ 11 ]. According to Bath [ 5 ], although a large clinical data storage warehouse may contain a lot of information, it could merely be a total sum of minor sets of data collected and may not be feasible for generalization.

Apart from this, missing data is also another issue and can have an impact on predictive analysis.

Implementing an Electronic Health Record System Health Informatics

The success of data mining depends largely on the availability of expertise, results derived from data mining and the interpretation of the results [ 5 ]. The process of data collection, storage and retrieval of personal medical information from individual patients has always raised ethical concerns when it comes to health informatics.

Thus, health informatics can cause concern when it comes to the management of health data and information. Security breaches can also occur when the health information is shared with others without prior consent of the individual. One way to overcome this is to have EHR secured with an encrypted password [ 13 ]. According to Layman [ 14 ], although health informatics is able to improve the quality of care and decrease the cost, it can create conflict for the ethical principles of autonomy e.

In order to ensure the success of the implementation of health informatics, one of the challenges is funding [ 15 ]. In government budgeting, it is common practice that a big portion of allocation is assigned to critical health care which is considered a priority.

As such, funds allocated for health informatics is very little.

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Although health informatics professionals and managers see the importance of the health informatics, the support from healthcare professionals and managers on the development of the ICT is lacking. This lack of support and understanding from the healthcare professionals may hinder the full potentials of ICT. Healthcare professionals may also end up making life-threatening decisions [ 10 ].

Thus, it is very important to involve the healthcare professionals in the development of decision support system and also to provide the salient information to the healthcare professionals on the importance and the application of ICT [ 10 ]. The data transferred into the system needs to be of high quality and accurate so that the safety and well-being of the patients are assured [ 5 , 10 ].

According to Bowman [ 16 ], although health informatics has substantial benefits such as better care and reduced healthcare costs, it can have some serious consequences. If the EHR system is poorly designed or inappropriately used, EHR-related errors can occur, which can endanger patient safety and at the same time reduce the quality of care.

With different systems used in various departments, it is difficult to integrate exchange or transfer information. As such a larger intraoperability architecture platform would be useful to integrate the similar system into various departments so that the exchange of information can occur [ 5 ]. The implementation of EHR can also pose many challenges. One of the challenges is it is expensive to develop EHR.

Apart from this, the functionality of each system may differ from one another and this can contribute to time consumption, slow processing, and not being user friendly. Also a lack or poor interoperability between the electronic medical records EMR systems can hinder other providers to communicate effectively. The information in the EMR needs to be accurate and reliable.

Otherwise, the quality of care will be compromised. Technological glitches are bound to happen when it comes to the use of EMR. As such data breaches may occur. The implementation of EMR may also affect the communication between physicians and patients and other physicians [ 17 ].