Electronic Medical Record Systems

Running head: ELECTRONIC MEDICAL RECORD SYSTEMS 1

Electronic medical record systems

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ELECTRONIC MEDICAL RECORD SYSTEMS 2

Electronic medical record systems

Introduction

Electronic medical record systems are established to streamline the flow of information

within the hospital setting. It is also utilized to increase efficiency in the storage and retrieval of

hospital records. In the hospital setting a lot of information or data is shared between different

departments this is because each hospital department plays a different role in the medical

environment. Some departments are used for running tests, others used to diagnose and observe

patients while, while additional are used to provide treatment. In addition to this, a hospital also

has an administrative, finance and management organ tasked with ensuring the backbone of

activities that facilitate the medical process are catered for.

The data or information exchange is also crucial for any process to be achieved within the

environment if records are misplaced or mixed the effects may be drastic an example is when the

patients’ blood group file is mixed with another, a blood transfusion that may result from such an

occurrence will be crucial for the patient's survival (Bowman, 2013). Biodata is very critical to

any individual it is considered private and protected by law against using it for other reasons.

In addition, hospitals also partake in different forms of treatment for the purpose of

research this procedure must be recorded for the purpose of gauging the viability of the process

based on successful attempts. This facilitates the implementation of the research based on its

success. If this information is not stored properly and efficiently it faces several risks such as loss

of information, unauthorized access to information, mixing up of records etc. This presents a

threat to the security of the information. If it falls into the wrong hand's additional risks are

pursuant to this. In some cases individuals seeking to kill an individual through advancement in

ELECTRONIC MEDICAL RECORD SYSTEMS 3

technology, people are now capable of creating bioweapons to target specific individuals

(Galliers & Leidner, 2014)

Organization Information

The organization of study is a hospital that utilizes a medical record system for storing

and management of clinical records and other administrative functions to be discussed further.

The system utilizes electrical powered devices to facilitate the transmission, storage, and

retrieval of records. This is achieved through the use of necessary hardware such as the system

unit and preferred peripheral devices etc. The hardware serves as the platform through which the

software is developed. The software then achieves the main function of the system.

Records stored in this system are divided into different types, the patients’ record form

the larger part of this system. The patient records store the patient’s vital personal information

such as name, gender, address, current home, next of kin, and blood group. This information is

critical in the identification of the patient. An additional element of the records then store his/her

previous history within the hospital, such as tests that have been done, diagnosis, and treatment

plans over the years. The records also stored in the system are lab records from different tests

performed for various patients.

Record keeping also moves forward to incorporate records of the doctors, nurses and

different staff or personnel employed by the hospital to offer different kinds of services.

Information stored about them may include personal details, department, attendance in times of

reporting and departure time etc. These records are linked to the patient's records to show who

conducted what activities in regards to treating the patient for accountability purposes.

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The medical records also have an aspect of procurement based on the resources utilized

the hospital has to record the different resources remitted to the staff to enable them to achieve

their tasks. In addition to this, it is also related to the pharmacy department that issues out

different drugs based on the doctor’s prescription. Lastly, the finance department also has

records of payments remitted by patients for different services rendered (Peppard & Ward,

2016).

All these records are connected through relationships this help in increasing the

efficiency of searching for specific information. It also provides an orderly manner of storing

information. The different records combined with their relationships form a larger database

system that is now called the electronic medical record system. The patient’s records are linked

to the entire database so as to provide sufficient tracking of all matters related to the patient from

expenses to drugs provided and the staff that handled the patients.

This system is supported by a networked platform that links every workstation to the

other, a server facilitates the storage and running of the database that can be accessed from

different workstations. The system is networked so as to ease the sharing of information from

one department to the other this enables the patient to be served faster and easily eliminating

risks that may result due to delayed services.

The system also operates in real time such that when any real time such that when a

record is updated from one end it is immediately reflected within the database. This minimizes

the logistics involved in updating files manually from previous records systems. This also

ensures that there are no gaps in records due to either loss of information or confusion within the

hospital's channels. The workstations comprise of a computer with a display attached to it are the

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necessary peripheral devices for the input and output of data within the hospital environment this

includes a keyboard a mouse, a printer for printing records or receipts for payments etc.

Reasons for development

The need for such a system was generated to increase the efficiency of medical

procedures from when a patient walks into the hospital to when they are diagnosed, necessary

tests are performed then treatment begins. In the olden days, records were stored in files a patient

was given a card that had a serial number and his or her personal details such as name and

address. When a patient walked into the hospital. They provided the reception with the card. The

receptionists then went through a bulk of files to trace the records for the patient. This process as

you can see is lengthy and cumbersome. After the records were traced the patient was then

directed to a queue to wait for their turn to see the doctor, meanwhile, the file was given to the

patient temporarily or sent to the doctor for review before the patients turn arrived (Lau, et al.,

2012).

Any tests performed were not entirely recorded but the results were transmitted to the

doctor physical this involved the lab attendant to move from their position and go to deliver the

results or in turn, give them to the patient. This process wasted a lot of time that could be used in

treatment. The process could also easily result in mixing up of records as the file changed hands

from one point to another. A lot of labor resource is wasted also in searching or sending the files

from one station to the other. This resource could be availed for more important functions such

as treating patients (Jensen, Jensen, & Brunak, 2012).

In order to minimize on this wastage and lack of efficiency in operations evident from

long waiting times. The hospital decided to implement an electronic recordkeeping system. The

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system was divided into the previously mentioned databases. In this new system once a patient

arrives their admission number and name is easily checked in the system. The system then

displays information pertaining the patient such as picture name and other details which are also

used to verify the identity of the patient and prevent impersonation. An appointment is then

booked with the doctor. On the doctors side the doctor is able to see the medical history of the

patient from within the system this is vital as a different doctor may be the one seeing the patient

from the one that was previously assigned to them. Therefore without consulting the previous

medical history, they may misdiagnose the patient if the patient does not clearly state their

history, this is based on the fact that a patient has minimal medical experience thus they might

not be able to categorize which bits of information is important and that which is not.

Once the doctor has reviewed the file they are now able to see the patient but before that

the nurse has to perform some pretests such as measure body temperature, blood pressure etc.

(Kuo, Liu, & & Ma, 2013). This information is stored in a new file generated for this hospital

visit the doctor then reviews this file together with the previous history while listening to the

patient’s description of what he or she is suffering from. If they can clearly deduct what the

problem is then instructions on treatment are provided if not additional tests are prescribed to the

patient.

From this system, it is clear that information flows smoothly from department to

department. It is also hard to confuse and update the wrong file as the nurses deal with one

patient at a time, in addition, the system can lock out an individual for periods of inactivity,

therefore, the patient is confirmed upon logging back again. This is one of the safety feature

added to the system to prevent such occurrences. Record keeping is also useful in tracing the

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medical history of a patient that is crucial for any diagnosis to take place (Middleton, et al.,

2013).

Information System Design

The information system design was based on two separate parts the hardware design that

concentrated on the hardware selection, network topology, storage and back up facility for the

system. The software part implemented the flow chart as described below that showed the flow

of activities within the systems from when the patient walks into the healthcare facility to when

they are diagnosed provided with treatment or prescriptions and finally leave the medical facility.

The database design shows the different records within the system and the relationship

shared between the different fields. This database design has the records divided into two parts

those that involve processes such as consultation, lab tests, and prescriptions while the other has

records containing information on individuals within the hospital setting. The records on

individuals are split into two the patients and the staff. The use of staff was preferred to

providing different tables for the different staff members as this would lead to an overwhelming

amount of data that do not contribute to the efficiency or systematic nature of the database.

Having a single record table for the staff is quite better, the table has the staff ID as the primary

field and below this field is the staff position that further classifies the staff based on their

position, this, later on, equates to their different responsibilities within the healthcare setting. The

other fields contain the personal details of the staff as seen in the patient's table.

The process records are managed by the personnel responsible for the different processes,

fields are allocated for entering results or conclusions from the process and each process has an

ID that can be used to refer upon tests from the different departments. In addition, each process

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is linked to the patient's ID and the staff ID for easier reference on who did the test and who did

the test belong too. This relationship provides further clarity to the records and eases the tracking

of records from different access points of the database this is illustrated in the diagrams below.

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Stakeholders and Responsibilities

Stakeholders refer to those people that helped in the creation and implementation of the

system. In addition, it may also include those who utilize the system to perform their day to day

obligations within the hospital. This hospitals record keeping system is an all-around database as

it encompasses individuals from different departments.

An electronic medical record system cannot be utilized in an individual department

within the hospital setting as it will not achieve the efficiency pertinent with information systems

thus to achieve this the system had to comprise of records from patients, physicians, lab

specialists, nurses, administrators. The system was an all-around data hub that enabled all

individuals within the hospital to contribute appropriately to the system based on their roles. The

different individuals had to outline their needs and problems they faced from utilizing the old

system. This brought about the gaps in record keeping and frequently lost information this a

system could be created to cater to this needs. To achieve this expert had to be brought in to

address these problems from an expert’s point of view through the incorporation of technology

that will lead to the creation of a robust information system (Stair & Reynolds, 2013).

An all-around information system was the only approach to implementing information

systems for only particular departments will still facilitate the same problems to be experienced.

The system experts combined efforts with an in-house team of technologists to develop a system

that caters to this needs.

Despite this sufficient planning had to be made this involved the hospital's administration

department and the relative finance department. This project will cost the hospital some capital

thus it had to be budgeted for in the most efficient way possible. This involved consulting with

ELECTRONIC MEDICAL RECORD SYSTEMS 11

both the in-house and outsourced team of developers (Stair & Reynolds, 2013). The appropriate

budget was achieved upon and taken to the board for approval. However, budgeting has not only

the task of the finance department. A committee had to discuss the different aspects of the budget

so as to harmonize it and achieve a common agreement. The hospital administration team was

also important in outlining the hospital's regulations and standards, in addition, they also ensured

the processes of administration were carried out in order this is in relation to common procedures

such as the admission of patients, referrals, emergency services protocol etc.

System Management and Implementation

The implementation of such a large system also had to be carefully planned as it involved

several departments and also affected several current practices in record keeping. This generated

the necessity that it had to be done in phases from one department to another or from one

procedure to the other. Nevertheless, it also involved other logistics such as the training of

hospital personnel on how to use the new information system and hardware that supported it. In

addition, the in-house technologists had to undergo orientation on how to manage the new

system and handle any arising problems.

The implementation began with the front office side of the hospital this included the

receptionists of various departments within the hospital. This is where the bulk of work was to be

experienced as most of the records are contained here and had to be transformed from analog

formats to a digital format for storage in the new system. However, before this stages even took

place the system has to be tested and ensured it is operating correctly as per the requirements of

the project committee tasked with catering for this new initiative.

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Training also took part in phases as taking all the staff for training will hinder the services

delivered by the hospital, therefore training will move from department to department, as all

members receive the necessary skills in navigating the new platform. Those involved in the

technical processes will also receive a similar training.

The management of the system will be divided to a departmental approach, whereby each

individual is responsible for their individual workstations. As for the hub of the entire system

which includes the servers, the network topology, and software, a committee is enacted to ensure

that appropriate follow-up is provided in maintenance and improvement capacity. This is done

periodically after every 3 weeks. The hospital also outsources highly trained experts for

problems that are beyond the internal individual's classification

Regulations

Regulations are essential for any business as they provide laws on how to conduct

yourself within the environment. In this case, the environment is the information system. This

system has to be managed appropriately as it holds vital information on patients. This

information has to be protected from unauthorized access use for personal gain. This includes the

selling of information to third-party individuals who seek to benefit from the trade. This act is

unethical and may pose some threat to the affected individual.

The government has also provided strict laws in the handling of personal information. It

says the information acquired should not be used for negative activities and or personal gain.

Nevertheless, information should also be kept for the sole purpose of improving the patient's

experience and if the need arises to use the information for other purposes consent should be

acquired from the patient (Stair & Reynolds, 2013).

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System Security

Security is necessary for any system to be considered to have integrity as is the objective

of any vital information system. Security with respect to Information systems is divided into two

unauthorized access or information loss. To curb system loss the necessary backup should be

implemented in avenues such as cloud computing. This will also save the company a lot of

money in generating their own security platforms that are already accessible from below. Data

loss should be always considered as the loss of the patient’s records will have a drastic effect on

the service delivery for hospitals.

Unauthorized access is restricted through providing the necessary platforms that included

firewalls to hinder hacking from external companies. In addition to this encrypted certificates can

be used to log in to the database or passwords. There should be a lockout period when the

workstation is logged into someone’s account and then changes to do something else.

Innovative Aspects of the System

The creation of medical record systems has really revolutionized the hospital setting as it

has increased the productivity in catering for patients. This is based on the time taken to provide

health care services for different patients. It has also minimized the errors brought about by

misdiagnosis that could lead to casualties this was achieved through prevention of loss or mix-up

of records. Hospital staff also now find it easy to render their services thus they are not worn out

by the previous taxing processes in healthcare, due to this they can now engage in decision

making when they are fresh this reduces the chances of mistakes in the profession (Weaver, Ball,

Kim, & Kiel, 2016).

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Medical record systems have also increased accountability in healthcare as each doctor or

nurse that attended to a patient can be tracked thus any issues that arise after treatment due to

negligence can be traced back to the individual involved. In addition, this minimized wastage of

resources or theft as through procurement systems within the hospital one can know who took a

certain machine and when they plan to return it. As in the case of drug abuse, most of the abusers

get their drugs from pharmacies or other venture, the sale will be now minimized based on the

strict records for prescription of medicine (Weaver, Ball, Kim, & Kiel, 2016).

Future Advancement

Future advancement for this hospital will involve the use of advanced system analytics to

foster intelligence within the system (Raghupathi & Raghupathi, 2014). Such initiatives will

enhance the capabilities of the system beyond record keeping to active use in decision making or

research. This would help the hospital plan appropriately for specific diseases and notice the

consistency in different symptoms this will aid in the determination of epidemics earlier before

they take effect. This may also be used to enhance automated diagnosis based on stated

symptoms and deductions provided by doctors in their diagnosis. Such a new system will help

nurses engage in diagnosis even when a doctor is not available. It can also be used as a training

platform for simulations.

Globalization has been achieved by the access provided by the internet linking up

different individuals to all parts of the world. Currently, DNA data can be collected and stored in

the hospital setting. Thus a donor list can easily be created to the specifics of the type of organ

required. By comparing it with an international health information systems donors from all over

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the world can be located and the necessary part is provided for their operations (Raghupathi &

Raghupathi, 2014).

Research in medical practices and procedures can also be implemented on a global scale

that will help the healthcare industry to grow in capacity by providing treatment for complex

diseases.

References

Bowman, S. (2013). Impact of electronic health record systems on information integrity: quality and

safety implications. Perspectives in Health Information Management.

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Galliers, R. D., & Leidner, D. E. (2014). Strategic information management: challenges and strategies in

managing information systems. Routledge.

Jensen, P. B., Jensen, L. J., & Brunak, S. (2012). Mining electronic health records: towards better research

applications and clinical care. Nature Reviews Genetics, 395-405.

Kuo, K. M., Liu, C. F., & & Ma, C. C. (2013). An investigation of the effect of nurses’ technology readiness

on the acceptance of mobile electronic medical record systems. BMC medical informatics and

decision making, 88.

Lau, F., Price, M., Boyd, J., Partridge, C., Bell, H., & Raworth, R. (2012). Impact of electronic medical

record on physician practice in office settings: a systematic review. BMC medical informatics and

decision making, 10.

Middleton, B., Bloomrosen, M., Dente, M. A., Hashmat, B., Koppel, R., Overhage, J. M., & Zhang, J.

(2013). Enhancing patient safety and quality of care by improving the usability of electronic

health record systems: recommendations from AMIA. Journal of the American Medical

Informatics Association, e2-e8.

Peppard, J., & Ward, J. (2016). The strategic management of information systems: Building a digital

strategy. John Wiley & Sons.

Raghupathi, W., & Raghupathi, V. (2014). Big data analytics in healthcare: promise and potential. Health

information science and systems, 3.

Stair, R., & Reynolds, G. (2013). Principles of information systems. . Cengage Learning.

Weaver, C. A., Ball, M. J., Kim, G. R., & Kiel, J. M. (2016). Healthcare information management systems.

Springer International Publishing.

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