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September 17, 2009
BY MARK WULKAN, M.D. The electronic medical record (EMR) is slowly transforming the way doctors, nurses, and other health care providers deliver patient care. Patients financial records have been electronic for decades; however, clinical data (the information entered by doctors, nurses, and other health care professionals) has been lagging. Processes for capturing lab and radiology results, history and physical details, operative reports, discharge summaries and other critical data have been very basic; paper charts remain the primary means of documentation and communication among the health care team.
Today, some hospitals are creating comprehensive EMRs for their patients that include the documentation and orders entered by all health care professionals. These EMR systems help:
Make it easier to access and share patient information among doctors, nurses, respiratory therapists and other health care professionals, regardless of whether they’re in the same unit, on separate floors or even away from the hospital. For example, if the doctor caring for your child in the hospital gets a call after she’s home, she can access nearly all the information in your child’s medical chart via her home computer (with the appropriate security clearance).
Allow your physician to order medications and procedures with the added benefit of EMR system “guard rails” that generate alerts to prevent errors, such as an overdose, giving a medication your child is allergic to, or prescribing drugs that are incompatible.
EMR systems designed for offices perform many of the same functions, just on a smaller scale.
Most of the top medical centers in metro Atlanta have implemented or are in the process of implementing a comprehensive EMR. Yet, the transition to comprehensive EMRs has been slow. In fact, a study published in the New England Journal of Medicine last year found that only four percent of physicians had a comprehensive EMR and 13 percent had a basic system. The primary barriers have been cost and time. Over the next several years, you should see an increase. The federal government is encouraging hospitals, clinics and doctors’ offices to do so and the American Recovery and Reinvestment Act includes stimulus money to help offset part of the cost.
In the future, as more EMR software manufacturers adopt international standards, your records will be electronically available from nearly any medical facility that you and your family visit. For example, if your child gets sick on vacation in Florida, you will be able to grant access to his pediatrician’s records and any previous hospitalization records to the Emergency Room doctor taking care of him. In addition, your pediatrician will be alerted and have the ability to access information about the ER visit. The details of how this will work are still being discussed, but this is the goal.
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