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Indry EMR

The medical record is traditionally paper-based but has limitations, while an electronic medical record overcomes these limitations and has advantages like increased connectivity, systematic information entry, easier compiling of large amounts of information, and more environmentally friendly storage. While an electronic medical record is better, it comes with increased costs of development, implementation, staff training, and continuous evaluation.

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Patrick Lukito
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8 views3 pages

Indry EMR

The medical record is traditionally paper-based but has limitations, while an electronic medical record overcomes these limitations and has advantages like increased connectivity, systematic information entry, easier compiling of large amounts of information, and more environmentally friendly storage. While an electronic medical record is better, it comes with increased costs of development, implementation, staff training, and continuous evaluation.

Uploaded by

Patrick Lukito
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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The medical record is essential documentation in healthcare.

It includes the patient’s


demographic information, health history, laboratory, and other examination results, and billing.
Its main purpose is to serve as a written form of communication between healthcare givers. It is
also important in the case of medical litigation as a form of evidence of the given healthcare.

The medical record is traditionally paper-based. However, a paper-based or written medical


record has several limitations. The information on the record is often only as clear as the
handwriting of the healthcare givers. As they have a lot of paper and reports to fill out, more
often than not, they do not have clear handwriting. This might lead to misinterpretation, which
could cause misdiagnosis and mistreatment. As a written medical record is not connected to the
internet, information sharing takes a substantially longer time. This is especially true when a
patient requires urgent care. His/her medical record is important in identifying any previous
medical conditions that might affect the current treatment strategy. A written medical record
would have to be first requested and searched in the storage room, and this introduces a
significant delay in treatment. Lastly, as it is stored in a physical form, creating a backup is
labor-intensive. Its storage would also require a large physical space.

Seeing the drawbacks of a written medical record, it is important to find a more effective
alternative. One such alternative is an electronic medical record. Unlike its written form, an
electronic medical record is usually filled through a computer and stored electronically on hard
drives. An intranet connection is usually available. By filling and storing a medical record this
way, a lot of the written medical record’s disadvantages can be overcome. By filling it in through
a computer, there would not be any unclear handwriting. This would reduce misdiagnosis,
mistreatment, and overall errors. Another advantage is the ability to connect several departments
of a hospital together. A good electronic medical record would be able to display inpatient,
outpatient, laboratory, radiology, and other departments together. This would give a more
comprehensive view of the patient. This increased connectivity also provides a better platform
for communication between independent departments in healthcare facilities. Any written
medical memos can now be stored electronically and automatically sent to the respective
department instead of handing a patient a written memo, which can easily be lost. This improved
communication would produce better coordination of care.
The electronic medical record can also be designed in such a way that information must be
entered systematically. For example, during a patient’s visit, information is entered sequentially,
beginning with his/her identity, demographic information, level of consciousness, vital signs,
complaints, physical examination findings, laboratory, diagnosis, treatment, and so on. This
would streamline the workflow significantly. Having a systematic medical record would also
reduce unwanted errors which could arise from having a medical record with an ambiguous
information flow. For example, a diagnosis should be made after adequate information is
obtained and not before. By having a sequential medical record, checkpoints could be introduced
at every level.

Another advantage of an electronic medical record is the ease of large amounts of information
compiling. A good electronic medical record, at the minimum, should be able to display records
of each diagnosis. This would make reporting much faster and easier. Healthcare facilities would
be able to obtain information regarding the number of each disease and use that information to
prepare better patient care. Moreover, this would reduce the burden of clinical research. A fully
integrated electronic medical record would be able to display all the patient’s information simply
by searching it electronically. Inputting the patient’s diagnostic electronically would also make
insurance claims much easier. In the era of Badan Penyelenggara Jaminan Sosial Kesehatan
(BPJS), this would reduce the work in claims. In BPJS, each disease has its own platform with a
set amount of reimbursement. By having an electronic medical record, a reminder could be set to
inform healthcare givers if the ordered examinations or treatments exceed the platform. This
would reduce the burden on the financial department.

Lastly, an electronic medical record is also more environmentally-friendly. This is especially true
in the case of radiology. Traditionally, radiology results are printed on a piece of radiographic
film. These films are classified as hazardous materials. Although they can be recycled, this
would introduce more cost and workload. Displaying the results electronically would remove
this environmental burden. Storage of an electronic medical record is also much easier as it does
not require a large physical space.

Overall, it can be said that an electronic medical record is better in almost, if not all, aspects. Its
problem lies in its development and implementation. As it is difficult for a healthcare facility to
independently develop an electronic medical record system, it is usually purchased from a third
party. A good electronic medical record does not come cheap. Moreover, if a written medical
record is usually organized by the medical record department, implementing an electronic
medical record would require an additional department, namely the IT department. The decision-
making process at the healthcare facility’s managerial level also requires dedicated time. Lastly,
as is true in the implementation of a new system, staff training and adaptation would be required.
Evaluation should also be done continuously, especially in the early period after its
implementation. All of these can be seen as increased costs.

In conclusion, an electronic medical record has a lot of advantages, but it comes with an
increased cost. The decision to implement one should balance the expected advantages and its
cost. An electronic medical record for a small clinic might be excessive, as the small number of
patients and information can easily be handled by a written medical record. An electronic
medical record would be more appropriate in a large hospital. The increased efficiency and
improved patient care would be worth the initial cost. This is especially useful in a teaching
hospital, where research are being conducted a lot.

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