Computerized Medical Records: Two Different Views

Computerized Medical Records: Two Different Views

Computerized medical records offer many advantages and some disadvantages.

In preparing to teach a preconference next week at the Academy of Medical Surgical Nurses annual meeting, I have been doing more reading about computerized records. We handle these records every day at med league, and sometimes find it challenging to organize and interpret them.

A publication by PriceWaterhouse Coopers, called Breakthroughs: HIT that Enables Quality, Efficiency, and Value came out last year. A unique blend of an article with links to audio and videos, it profiles four healthcare systems and their implementation of Health Information Technology.

The article stimulated these insights:

  • Healthcare is an information business. We rely on being able to access data. In the legal world, we rely on medical records to reveal the details of care.
  • If all of the information is not available to those who need it at the point of care, medical care cannot be cost efficient or effective. If all of the details needed to evaluate liability or damages are not in the medical record, legal professionals are hampered.
  • Health information technology must be well-integrated into the work of an organization. It should not automate inefficient practices. Its use should also not obscure other people’s understanding of the details of care.
  • In organization after organization, physician resistance or acceptance of computerized medical records can make or break a system. In many medical records we review, physician progress notes are among the last documents to be automated, and contain the most difficult to read handwriting.

At Hackensack University Medical Center, a cancer center collects data about outcomes, to gauge the effectiveness of various treatments.

The use of computerized medical records provides more job security for employees and improved use of data for patients. Healthcare systems with robust electronic records may experience improved efficiency and reduced waste in care.

When there is better coordination of information among various providers, patients will have better access to their healthcare information, and their providers will be able to more readily share information. This should reduce medical errors and duplication of services.

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.

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