Electronic Medical Records

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Introduction

An electronic health record (EHR) (also electronic patient record (EPR) or computerised patient record) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems. Such records may include a whole range of data in comprehensive or summary form, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information.

Purpose

Its purpose can be understood as a complete record of patient encounters that allows the automation and streamlining of the workflow in health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting.

Data Types

There has been different definitions to describe the use of electronic systems to collect patient data. While these terms have been used interchangeably, each of them has their own specific use case ;

1. The Personal Health Record (PHR): An individual and personal account for medical history in a digital format.
2. The Electronic Medical Record (EMR): A provider-based system that includes all documentation for a patient covering all services provided within an enterprise.
3. The Electronic Patient Record (EPR): A patient-centered system containing only patient documentation

These systems are structured around their technical capabilities, which will determine factors of stored data such as type and quantity, such as;

• Medical imaging devices can store the raw data of the screening within each patients file
• Video recordings of surgical interventions or medical tests can be archived within capable systems
• Internal memos and notes can be stored in their relative fields as text
• Correspondence with third parties can also be stored (Pharmacy, patients, government agencies etc.)
• Legal documents such as consent forms can be backed up and accessed digitally to ensure safe medical practice

Electronic devices can be networked to allow spontenous access and/or uploading of all these data types. An internet connection via a secured network will also enable syncronazation between buildings and organiziations.

Role in Research

Electronic data systems can be used in clinical research environments to support clinical research processes. institutions which are dedicated for research can benefit from specific form design, documentation, clinical decision support, and research protocol order sets. This approach can enable easier adherence to legislations while making easier creation of accumulative and re-usable data. This in turn can provide valuable large datasets for refining further research efforts.

Security

The 2021 HIMSS Healthcare Cybersecurity Survey gives valuable information with the help of healthcare cybersecurity professionals that has responsibility for day-to-day cybersecurity operations. The findings of this annual survey will provide health professionals with the insight and awareness for using electronic data systems.

For 2021 important bulletpoints of the survey is as follows;

• Phishing is the most prominent malicious attack vector for these systems, health professionals being a primary target because of their access.
• These malicious attacks generaly aim to gather information of financial value. Financialy valuable data should have higher standards of security and access.
• Disruption of these systems, which some institutions heavily depend on, can occur during these attacks. There should be contingincies in place for such scenario to continue health care services.

EHR in Physiotherapy

Physiotherapy services can benefit from the electronic data approach. There have been attempts to implement such systems which paved the way for the specific design needed in therapy. Tele-rehabilitation also accelerated this process due to its remote and digital natüre. These systems can hold examination, diagnosis, treatment plan and patient history data built around the ICF. While the advanteges are clear, there remains the process of certifiying these systems for general use and security along with the implementation to current clinics. Pilot studies are conducted to understand the current attitude of clinicians to these systems have reported a critical need for digital literacy, motivation and an understanding fort he advanteges of electronic record systems among physiotherapysts.

References

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