Presentation on theme: "ELECTRONIC MEDICAL RECORDS By Sh. Ananthakrishnan Technical Director, NIC."— Presentation transcript:
ELECTRONIC MEDICAL RECORDS By Sh. Ananthakrishnan Technical Director, NIC
Medical Records – Objectives Review patient care, appropriate take clinical decisions & develop treatment plans Provides an archival and legally acceptable record Provides material for researchers Act as a source of information for heath administrators
Medical Records – Objectives Enables for hospital auditing Be stored in such a way that it is available when required Be subject to access controls to protect patient privacy, to avoid un- authorized/misuse
Medical Records – Present status “The (paper) medical record is an abomination …it is a disgrace to the profession that created it. More often than not the chart is thick, tattered, disorganised and illegible; progress notes, consultant’s notes, radiology reports and nurses notes are all co-mingled in accession sequence. The charts confuse rather than enlighten; they provide a forbidding challenge to anyone who tries to understand what is happening to the patient.” Bleich,H
Medical Records – Present status Finding and reusing key data items Record fragmentation Movement of paper information Lack of support for decision support systems
Medical Records The safe and cost-effective practice of medicine is becoming increasingly complex, and relies more and more on knowledge of the results of recent research into causes, manifestations, diagnosis and effective treatment of illness.
Medical Records Knowledge-based decision support tools are increasingly being used and are likely to prove invaluable as a means of ensuring and assuring best quality care and practices for all patients. However, the only efficient way of using them is to hold the medical records in an electronic form with which these tools can interact directly.
Electronic Medical Records Availability, transfer and retrieval Linkage Storage Data Views Abstraction & Reporting Data Quality and Standards Decision Support
Obstacles – Electronic Medical Records Technology Investment Adoption by the user Modification of existing practices Understanding of legal and ethical issues Holistic view of the service to the patient
Medical Records Computer networks for electronic exchange of medical records PACS HL7 and DICOM standards Computerized medical reporting systems Smart cards Web based medical reocrds availability
Medical Records – Where we stand Present status of medical records in Govt. hospitals Non-availability of medical records for OPD services Non-availability of area-specific morbidity Integrated diseases surveillance system Health infrastructure assessment – National commission for macroeconomics and health