Essay Sample: Manual Health Records vs. Electronic Health Records

Relationship between EMR and EHR and TPMS

Electronic medical record (EMR) refers to a single practice digital form of a patient's chart. It contains details of a medical history of a patient, diagnosis and treatment interventions by a particular practitioner such as a clinician, nurse, physiotherapist among other health caregivers. Electronic health record (EHR) is a more comprehensive digital form of a patient's chart offering patient's data beyond a single practitioner. EMR contains patient's data from various caregivers and allows sharing of information among different authorized practitioners attending to the patient such as a nurse, surgeon, and pharmacist among other healthcare specialists. Total practice management software (TPMS) refers to software used in developing EMR and automating various medical practices such as inpatient health management, producing clinical reports as well as in other non-clinical functions such as records of patient's medical insurance and processing payment. These records are in turn used to generate EHR (Mann et al, 2011).

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Advantages and Disadvantages of Manual Health Records

Advantages and Disadvantages of Electronic Health Records

A rationale for a Recommendation to Move to EHR

The rationale behind the implementation of EHR in a private clinic will be to improve communication between various departments, standardize, and improve quality of care given to the patients. The ability to access records between various clinic departments such as outpatient, lab, pharmacy, dental among other units allow professions to access patients records simultaneously without using fax or physical delivery of files. This aspect results in faster and more efficient care. There is better accuracy in EHR that eliminates most medical errors due to miscommunication (Boonstra et al, 2014).

Plan of Transition from Manual to Electronic Records

An effective plan of action is crucial for a smooth transition.

Assessment Need Performance

Assessment of performance will involve assessing the needs to implement the move including the capability of staff, computer and other electronic requirements and finances. The staff should be ready and if necessary training should be conducted to ensure they understand all the aspects involving the operation of the system and more importantly how to use the records without exposing the information to unauthorized people. The computer system should include security software to protect the records to be accessed by only the clinic staff.

Workflow Analysis

Workflow analysis involves checking patient's aspects to ensure they are not affected by the changes. Such elements include visit schedules, planned diagnostic tests, billing among others fundamental requirements. The workflow analysis requires input and output information such as entering demographic records as well as their medical history into an electronic system.

Envision of the Future

There is a need to consider and assess how the future will appear for the patient as well as other clinic staff members. Necessary training on the use of the system should be considered to ensure staff enters and access the correct records. They should be given unique codes or password to access the records.

Road Map to Select and Implement the System

Roadmap plan involves step by step process to be followed. The process comprises several steps, but the main consideration should be preparing the staff, identifying reliable vendors who will not compromise record security, testing the system primarily on accuracy and security aspects and finally converting the records to electronic form.

References

Boonstra, A., Versluis, A., & Vos, J. F. J. (2014). Implementing electronic health records in hospitals: a systematic literature review. BMC Health Services Research, 14(1), 1-24.

Mann, D. M., Kannry, J. L., Edonyabo, D., Li, A. C., Arciniega, J., Stulman, J., ... McGinn, T. G. (2011). Rationale, design, and implementation protocol of an electronic health record integrated clinical prediction rule (iCPR) randomized trial in primary care. Implementation Science, 6, (1), 1-10.