Electronic Medical Records

Information gathering and analysis has been central to the effective delivery of healthcare. Most of the information generated in healthcare organisations is centred around the patient and such information about individual patients are kept in confidential records known as medical records.

The information contained in these records include the patient details (such as name, sex, date of birth, occupation and address), the patient’s medical history and any other relevant history, and a complete report of each event with the patient, from signs and symptoms when first presenting, through diagnosis and investigations to treatment and outcome. Other relevant information and documentation also need to be added.

For a long while, healthcare organisations have kept paper-based records but they have their shortcomings, some of which include:
An increasingly mobile society means that people now change their family doctor more often and these paper records have to be physically to the new doctor’s practice.
It is difficult to find specific information in paper-based records, increasing the possibility of missing vital information that might be hidden within a cluster of non-relevant data.
Paper records are hand written and these might be difficult to read or interpret by healthcare professionals other than the author.
Paper records make the use of decision support systems extremely difficult especially during consultations.

Electronic Medical Records (EMRs) have been introduced to address these issues and it is now possible to store part or whole of a patient’s record on a computer.

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HOSPITAL INFORMATION SYSTEMS

A hospital information systems (HIS) is a computer system that is designed to manage all the hospital’s medical and administrative information in order to enable health professional perform their jobs effectively and efficiently.
Hospital information systems were first developed in the 1960s and have been an essential part in hospital information management and administration. Early systems consisted of large central computers connected to by dumb terminals, which are now being replaced by networked microcomputers. The systems were used to manage patient finance and hospital inventory.

Hospital information systems now focus on the integration of all clinical, financial and administrative applications and thus could also be called an integrated hospital information processing systems (IHIPS).
Components of a hospital information system consist of two or more of the following:
Clinical Information System (CIS)
Financial Information System (FIS)
Laboratory Information System (LIS)
Nursing Information Systems (NIS)
Pharmacy Information System (PIS)
Picture Archiving Communication System (PACS)
Radiology Information System (RIS)
A look at the list above shows how complex a hospital information system can be. Advancement in computer technology and the development of information exchange standards such HL7 and DICOM, make the task administering and integrating such systems a little more easier.
No hospital information system can be regarded as a success unless it has the full participation of its users. Thus human and social factors would have to be considered in its design, more often than not, they can be easily addressed by providing adequate training and education about the system.



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