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Medical Recording Tools: EMRs and PMRs Report (Assessment)

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Updated: Mar 12th, 2020

Introduction

The health care industry has evolved significantly over the years with better ways for providing care being developed. One of the areas that have experienced innovation is in medical records. Medical records are important tools for physicians since they provide the means for recording patient condition and serve as the basis for medical interventions.

Paper-based Medical Records (PMRs) are the traditionally used tools while Electronic Medical Records (EMRs) have emerged as a new system that is intended to replace PMRs. This paper will discuss the two tools with focus on the differences between them. It will also highlight EMRs are favored over PMRs and the inherent problems in implementing EMRs.

Difference between PMRs and EMRs

The main difference between PMRs and EMRs is that while PMRs are manual, EMRs are electronic. In the PMR system, the physician writes down the patient’s information on paper or chart. These records are then stored in files which can be kept in a cabinet for safekeeping.

EMRs are essentially digital versions of PMRs and the information is entered into a computing device and saved electronically in the devices memory (Rustagi and Singh 142). The health care institution might save information medical records for multiple patients in a central server.

Another difference is that PMRs do not have any format restriction and the doctor is free to enter information in the forms that suits him/her. The doctor might choose to include a detailed historical record of the patient or just give a brief overview.

With EMRs, there is a format restriction since the doctor has to use a predefined template when entering patient data (Lau et al. 1). Some of the systems are configured in such a way that data must be entered in all available fields. The doctor is therefore forced to fill data for the patient in a consistent style.

Information contained in an EMR

Typical EMRs contain all the information that the traditional PMRs have. This includes the general patient information such as gender, age, name, and address. In addition to this, EMRs contain patient’s medical history, the diagnosis done by the doctor, tests conducted, treatment given, and the next appointment date (Rustagi and Singh 142).

The EMR also provides space where the physician can make additional notes on the patient. Some EMR systems offer templates and have auto-fill functions that enable the doctor to fill in data from an exhaustive database of medical information.

Merits of Implementing EMRs

EMRs help overcome some of the basic problems that arise due to the use of PMRs. EMRs assist in the reduction of medical errors by providing physicians with quick access to the patient’s medical history and relevant medical information to assist in prescription (Lau et al. 1). The decision-making ability of the doctor is therefore enhanced due to quick access to information through the electronic systems.

EMRs make it easier for physicians to communicate between or among themselves as they provide medical care to a patient. PMRs suffer from the setback of illegibility, inaccurate or incomplete information, and inconsistency. When a patient is transferred to another doctor, obtaining their medical history is hampered by PMRs.

With EMRs, doctors enter information into a computer system in a readable and consistent manner (Tang, LaRosa and Gorden 246). The information is also complete which makes patient transfer easy since the new physician will have access to complete medical records of the patient.

EMRs assist doctors in their billing tasks ensuring that the doctor is properly compensated. By use of the coding levels contained in EMRs, physicians can bill patients according to the services provided (Rustagi and Singh 144). This ensures that no monetary losses are incurred due to down-coding by doctors who lack confidence on how to bill patients.

Problems with EMRs

Implementing EMRs is expensive and doctors must spend a lot of money when setting up the system. Brooks and Grotz estimate that an individual doctor will spend between $30,000 and $60,000 to implement an EMR (74). Most physicians may lack the knowledge necessary to fully utilize the EMR in their practice. This will make it hard for the initial investment in the system to be recovered.

Like any computer system, EMRs are prone to bugs and system failure. A widespread system failure can be catastrophic since it might cause the loss of valuable patient data (Rustagi and Singh 145). Some hospitals keep manual backups of patient records because of this risk.

EMRs raise major privacy concerns for patient health records. To begin with, doctors enter a lot of personal patient information into the EMR database. Since the records are stored in an electronic format, it is easy for an unauthorized person to access and copy patient records (Tang et al. 246).

If this security breach occurs, private patient information might be available to the public. These issues have prevented the widespread endorsement of EMRs by the public.

Conclusion

EMRs are gaining popularity due to the various advantages they present over PMRs. This paper has defined EMRs and offered some of the rationale favoring their implementation and use. A list of some of the problems posed by EMRs has also been given. Even though EMRs are not perfect, they are more effective and efficient than PMRs and their widespread adoption in our health care system can be expected.

Works Cited

Brooks, Rayne and Grotz, Calz. “Implementation Of Electronic Medical Records: How Healthcare Providers Are Managing The Challenges Of Going Digital”. Journal of Business & Economics Research 8.6(2010): 73-84. Print.

Lau, Francis, Morgan Price, Boyd Jeanette, Partridge Colin, Bell Heidi, and Raworth Rebecca. “Impact of electronic medical record on physician practice in office settings: a systematic review”. Lau et al. BMC Medical Informatics and Decision Making 12.10 (2012): 1-10. Web. 21. Mar. 2013.

Rustagi, Neeti and Singh Ritesh. “Electronic medical record: Time to migrate?”. Perspectives in Clinical Research 3.4 (2012): 142-145. Web. 21. Mar. 2013.

Tang Paul, LaRosa Michael, Gorden Susan. “Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions”. J Am Med Inform Assoc 6.3 (1999): 245–251. Print.

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