SAN DIEGO--Health care pro-viders around the world have embarked on the road toward electronic records, but nobody has quite reached the destination, according to Peter Waegemann, executive director of the Medical Records Institute, based in Newton, MA.
Mr. Waegemann gave a talk at an MRI conference in mid-May. "Health care is changing," he said. "And it all depends on information flow. If you have a patient record system fully computerized, you have a nerve center for information."
Automated medical record. This is the level representing most of today's computer use among health care professionals, Mr. Waegemann explained. Information stored on a standard personal computer doesn't comply with legal requirements for electronic medical records, so a paper file must be maintained. The computer information is used as a working file, and then pages are printed and filed in the chart.
Computerized medical record. At this level, physicians and staff collect information on paper and scan it into the computer. As with the automated medical record, it's departmentalized, so patients must provide their names and other information each time they visit a different department. However, the computerized medical record addresses some legal issues--such as preserving data integrity--because information can't be altered on screen.
Electronic medical record. Information from all departments in an enterprise would be accessible through the same system. It would eliminate the need for paper records because it would meet legal requirements for confidentiality, security, accountability, and data integrity.
Electronic patient record. This level reflects the Medical Records Institute's vision: a system that would link all patient information, including data from outside the enterprise. Emergency room services, primary care, mental health treatments, fitness training, dental care, and all other health care would be accessible via one database. Before this level is reached, a number of issues--such as national patient identifiers and privacy--need to be resolved, Mr. Waegemann said. "Do you really want your dentist looking through your OB-Gyn records?"
Electronic health record. This ultimate level in computerized patient records would place some responsibility on patients to keep track of their own health. Patients would record their own health information to supplement data from health care professionals. "You and your children should all have your own health records and you should be in charge of the information," Mr. Waegemann said.
"Computers and Family Practice" contents
FP Report, July 1996 headlines
More information about FP Report
