Medical Essay on Electronic Health Record System

In 1980, Dr. Tom Martin, a graduate of the University of Maryland, opened the UMUC Family Clinic which was near UMUC, Maryland. He owns and manages the internal medicine medical practice. He hired two nurses, Vivian and Manuella to assist him with the front desk duties and throughout the patient visits. They rotate the functions and are continuously busy, and the patients have to wait at least 1-2 hours before their needs are sorted. When one of the nurses is absent, the situation becomes worse. Therefore there is a need for an Electronic Health Record System.

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An Electronic Health Record System (EHRS) refers to the individual information that is created, gathered, managed and consulted by authorized clinicians and staff. The EHRS will improve the providers' performance, quality, and continuity of care and the availability of data in the UMUC Family Clinic. The system will enable the nurses to store information about their patients and also schedule appointments easily. The system will be appropriate for the Clinic especially in situations whereby one of the nurses is absent. The other nurse will be able to handle and easily refer to the system thus minimizing the long hours of waiting for the patients as the records are readily available therefore providing efficient checking in for walk-in patients.

The Electronic Health Record System makes it easy for the UMUC Family Clinic to share their information with external organizations such as laboratories and pharmacies. There is need to share patients data such as the type of medicine prescription to the pharmacies and laboratory test results received from the laboratories. The system will be able to send the information to the pharmacies and receive the data from the lab efficiently. Laboratory test report includes data elements that are considered the core unit of information that is collected, stored and used in the clinical information system (Musen & Van Bemmel, 2014).

The data elements that UMUC Family Clinic should send to the laboratory includes patient name, gender, health status, medical history, clinic address, phone number, health ID number and the diagnosis. The lab should send the test results to the doctor for further considerations. Data elements forwarded to the pharmacies include; patient name, any allergies, the medication used by the patient, health ID, provider ID, prescriptions and previous medications from pharmacists. The pharmacy sends the prescribed medicine suitable for the patient. When using the Electronic Health Record System, the data flow process will be quick, reliable and can be used for future reference as opposed to keeping paper reports that may be lost and misfiled.

The two types of data interchange include; Health Level Seven (HLS7) and Systematized Nomenclature of Medicine-Clinical Terminology (SNOMED-CT). HLS7 is known for content exchange standards for electronic health information whereas SNOMED-CT is the standard of representing electronic health information. The HLS7 system guides the sharing of patients healthcare information and revenue. SNOMED-CT improves the accuracy of patient data analysis. Legal consideration of data exchange includes protecting the patient health records and providing backup content when systems fail. Regulatory considerations include regulating the use and disclosure of independently identified information by health providers. The patients information should not be released without their consent. Ethical regulations ensure that clinicians maintain the rights of the patient promoting doctor-patient confidentiality.

References

Collen, M.A. (2014). History of medical informatics in the United States. American Medical

Informatics Association. Washington, DC.

Musen, M.A., & Van Bemmel, J.H. (2014). Handbook of medical informatics. Houten: Bohn Stafleu Van Loghum.