8/11/2019 Annathkrishnan, Annexure G

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ELECTRONIC MEDICALRECORDS

By Sh. Ananthakrishnan

Technical Director, NIC

8/11/2019 Annathkrishnan, Annexure G

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Medical Records  –  

ObjectivesReview patient care, appropriate take

clinical decisions & develop treatment plans

Provides an archival and legally acceptable

record

Provides material for researchers

Act as a source of information for heath

administrators

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Medical Records  –  

ObjectivesEnables for hospital auditing

Be stored in such a way that it is available

when requiredBe subject to access controls to protect

 patient privacy, to avoid un-

authorized/misuse

8/11/2019 Annathkrishnan, Annexure G

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Medical Records  –  

Present status“The  (paper) medical record is an abomination …it

is a disgrace to the profession that created it.More often than not the chart is thick, tattered,disorganised and illegible; progress notes,consultant’s  notes, radiology reports and nursesnotes are all co-mingled in accession sequence.The charts confuse rather than enlighten; they

 provide a forbidding challenge to anyone whotries to understand what is happening to the

 patient.” 

Bleich,H

8/11/2019 Annathkrishnan, Annexure G

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Medical Records –  

Present statusFinding and reusing key data items

Record fragmentation

Movement of paper information

Lack of support for decision support

systems

8/11/2019 Annathkrishnan, Annexure G

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Medical Records

• The safe and cost-effective practice of

medicine is becoming increasingly

complex, and relies more and more onknowledge of the results of recent research

into causes, manifestations, diagnosis and

effective treatment of illness.

8/11/2019 Annathkrishnan, Annexure G

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Medical Records

Knowledge-based decision support tools are

increasingly being used and are likely to

 prove invaluable as a means of ensuring andassuring best quality care and practices for

all patients. However, the only efficient

way of using them is to hold the medicalrecords in an electronic form with which

these tools can interact directly.

8/11/2019 Annathkrishnan, Annexure G

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Electronic Medical Records

Availability, transfer and retrieval

Linkage

Storage

Data Views

Abstraction & Reporting

Data Quality and Standards

Decision Support

8/11/2019 Annathkrishnan, Annexure G

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Obstacles –  Electronic

Medical RecordsTechnology Investment

Adoption by the user

Modification of existing practices

Understanding of legal and ethical issues

Holistic view of the service to the patient

8/11/2019 Annathkrishnan, Annexure G

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Medical Records

Computer networks for electronic exchange

of medical records

PACS

HL7 and DICOM standards

Computerized medical reporting systems

Smart cards

Web based medical reocrds availability

8/11/2019 Annathkrishnan, Annexure G

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Medical Records –  Where we stand

Present status of medical records in Govt.hospitals

 Non-availability of medical records forOPD services

 Non-availability of area-specific morbidity

Integrated diseases surveillance systemHealth infrastructure assessment  –  National

commission for macroeconomics and health

8/11/2019 Annathkrishnan, Annexure G

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