medicines and medical science is the biggest event in the history of
mankind. From ancient times till few centuries back the patients were
treated successfully by the physicians, but there were hardly any
records available for every case they handled and every aspect of that
case. We have lost that data, which could have been helpful in the
modern medicine world. Many special treatments given for particular
symptom, any different kinds of techniques used while treating the
patients or any new type of medicinal formulas have gone under the cover
of undocumented history. When we understood the need of recording the
data in healthcare sector, it gave rise to different types of medical
records were mostly handwritten. Slowly the report typing system was
introduced. We faced multiple disadvantages with this type of
- There was no copy of the records, so if
the record gets misplaced/damaged there is no backup for the
- Handwritten documents were many a times
illegible, so the data extracted from those documents was
- Damaged handwritten documents used to get
fade up, which was again a problem in integrity of the data.
- Archival of those records was a big
- Handling those records was
- For any purpose those documents were
needed to get reorganized manually.
- As it was based on manual activity, most
of the times the data on the actual record was incomplete.
- There was limitation for data capturing
due to dependability on type of data (graphical reports were
difficult to capture as a medical record).
- Portability of the documents and
transferring data to the other center was a headache.
- Records were misplaced multiple times and
no copies were available for the same.
- During that period the importance of the
medical data was not very well understood and therefore medical data
privacy and ethical practices were not much implemented for any
- Data capturing on timely basis was time
consuming and difficult for the healthcare professionals.
Electronic Health Records
extended its tools to help medical domain in solving these problems.
This has given rise to the concept called Electronic Medical
Record, widely accepted and
practiced these days and also known as EMR. This brought revolution in
the field of medical data
data for any patient on computers, storing it in the small hard drive,
reviewing the same data again and again, easy updating and editing the
data are few of the key benefits this system has provided to us.
Types of EMR:
records start with entering the patient with his/her specific ID numbers
to the computer. Adding history of the patient including social, family,
past medical, surgical history and medicinal history generates initial
intake report, which is used and updated every time the patient visits
- Various office notes, chart notes, therapy
notes generated date wise provide detailed information of the
treatment flow of that patient.
- Operative reports, nurse’s reports,
assessment and flow sheets, discharge summaries provide accurate
data for every minute spent during hospital admissions. These also
include various graphs, which add value to the data. They are also
system generated and a part of medical health record.
- Ante-partum records, birth records,
development records, death records and also postmortem reports has
their own importance.
- Various MRIs, CT scans, laboratory
studies, x-rays and other diagnostic studies are reported via
electronic medical records only.
Advantages of EMR:
- Data can be stored and can be reviewed
multiple times, got rid from pills of files.
- Editing and updating the data is
- Electronic capturing system forms make
sure that the data is complete and with the latest technology we can
be sure about the integrity of the data.
- Medical data privacy and ethical practices
can be very well implemented as part of HIPAA privacy rule.
- Secured portability of the data is
possible using this latest technology.
- Damage to the data is very rare and can be
- Illegible data is no longer a
- Archiving a large amount of data is cost
effective, safe and easy.
- Reduced data capturing time.
- Very easy to handle and generate.
- Require less space.
- Reorganization of the medical records is
Scope of EMR:
All the leading
countries and developing countries are using EMR in their day-to-day
medical data capturing.
- Past records are required in deciding
- Analyzing the effectiveness of drugs in
- In insurance/claim processing.
- In deciding disability status.
- For any medico-legal actions.
- As a part of police investigation.
- Employment scanning.
- Drug dispensing and monitoring
- Auditing research and evaluations.
Laws for EMR:
The laws, rule
and regulations change in every country for
- Archival period.
- Destruction of EMR.
EMR indeed is a
bestowal as it has improved the quality of healthcare
services and healthcare
professionals can now focus more on the core work by spending very
minimal time and energy on EMR.