Introduction To Electronic
Medical Records
Y. SINGH
NELSON R. MANDELA SCHOOL OF MEDICINE
DEPARTMENT OF TELEHEALTH
SINGHY@UKZN.AC.ZA
HIBBs is a program of the Global
Health Informatics Partnership
Content licensed under Creative Commons Attribution-Share Alike 3.0 Unported
Learning Objectives
 What a electronic medical records
 Disadvantages of paper based records
 Examples of electronic medical record system
 How to assess the benefit of a computer
based record system
Introduction
 Medical chart or medical record
 Comes from the idea of patient information
 Why should a doctor write these notes?
Too recall observations, to inform others, to instruct
students, to gain knowledge, to monitor performance,
to justify interventions
Disadvantages of paper records
 Organisational:
 Information storage and retrieval
 Logistical:
 Wear and tear
 Back-ups
 Can only be at one place at a time
 Research
 Passive nature
Electronic Medical Records
• EPR - Electronic Patient Record
• EMR - Electronic Medical Record
• CbPR - Computer-based Patient Record
• CPRS - Computer Patient Record System
• EHR – Electronic Health Record
What’s the Difference?
 What is the difference between a CPR and an
EMR?
Patient orientated
Comments by Clinicians
Video One and Two
Technology Intervention
 Use of database technologies
 Information retrieval
 Different levels of use
 Structured vs unstructured
 Scheduled back-ups
 Semi or automatic data entry
 Voice, handwriting recognition, direct entry via
keyboard
 Templates
 Data communication
Technology Intervention
 Security

Unwarranted fear

Strong passwords

Encryption and digital signatures
 Clinical decision support systems
 Cost savings
 Improve quality of care
BUT ….
Problems
 Technology:
 Infrastructure
 Training and expertise
 Perception
 Human Factor
 May create discord
 Change management
Assessing Benefits
 Are all EMRs benificial?
NO
Comprehensiveness of information
Duration of use and retention of data
Degree of structure of data
Ubiquity of access
Workflow
Etc etc etc etc etc etc etc etc etc etc etc …
Components of a EMR
 Integrated view of patient data
 Clinician decision support
 Clinical order entry
 Access to knowledge resources
 Integrated communication support
Issues with CPR – Data entry
• Data Capture
• Data Input
• Error prevention
Issues with CPR – Data Display
Bruce Slater
Thank You
HIBBs is a program of the Global Health
Informatics Partnership
www.ghip.net
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