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

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 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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