Electronic medical records are computer-based patient medical records. Physicians’ offices and hospitals throughout the United States are increasingly using them because they offer certain advantages over conventional paper-based medical records. Such records are also useful in processing health insurance claims and following up with patients. A key benefit to medical providers is the instant availability of data once it is entered electronically, and the space and labor savings resulting from the elimination of paper-based records.
Electronic medical records are readily accessible, increasingly standardized for seamless use where and when required, and greatly reduce the likelihood of error in either entry or interpretation of medical information. Having a patient’s medical and contact information readily available can be potentially life-saving during critical medical events such as severe allergic reactions or heart attacks. By reducing errors and saving time, electronic medical records may therefore help reduce the large number of deaths attributed to medical error in the United States each year.
In order to enter medical information into an electronic medical record, special software is required. The electronic medical records software industry is rapidly growing, and such software is becoming increasingly sophisticated. While basic software allows for entry of physician orders and notes and nurses’ notes, more advanced software may include error-checking programs, the capacity to synchronize with hand-held data devices, and other advanced features that increase the utility of records.
As electronic medical records are more widely used, concerns regarding the protection of patients’ confidential medical information and privacy have increased. In 1996, the US Congress passed the Health Insurance Portability and Accountability Act (HIPAA), and a more stringent Privacy Rule went into effect in 2003. HIPAA sets required national standards for medical records, guarantees patients the right to see their own medical records, and requires providers to inform patients how their medical information is used and disclosed.
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