Documenting medical data on paper was a common praxis for many years.
In the more recent past, hospitals used specialized documents and paper charts to input patients’ data.
Nurses with decades of experience maybe remember the past protocols, for example using only black ink, circling assessments, using patterns of dots and arrows, etc.
There were all kinds of protocols in the past, many of which don’t make sense in modern medicine.
Electronic medical records (EMRs) were introduced to make order in the documentation, to standardize, to prevent error, promote concise documentation, and have a long-term option for storing data and ensure simple access to them.
The years of EMRs use showed the advantages and disadvantages of using the electronic way of storing data.
Pros of Using EMRs:
EMRs are a standard way of keeping track of patient data and healthcare workers’ notes, test results, and treatment processes.
EMRs provide simple access to the data for all healthcare team.
Also, other healthcare facilities can access the data and reduce the data for communication.
The most important aspect of EMRs is the lower probability of errors.
There is no risk for misinterpretation of handwritten notes or transcription errors.
The modern EMRs have a system to prevent incorrect inputs and to promote a standard way of data entry.
For example, if you have to put in the dosage, there is a way to do it without any misinterpretation.
EMRs assists and help medical staff to be more productive and focus on patient wellbeing, rather than on administration.
Barcode scanning, for example, is quite convenient, because it helps to identify the patient.
Therefore, there is a lower risk of giving reverse medicines, mixing the test results, etc.
EMRs help to make the process complete without skipping on some important procedures.
The system will note you if there are some fields left blank which can be important in the further treatment protocol.
The new system of storing medial records improves patients’ privacy and security.
It prevents the misuse of a paper document and the sharing of private information.
Paper charts that are on the way to some external facilities are even at higher risk of a privacy breach.
To access EMRs, you will have to have permission.
Some data requires the highest level of permission, and not every healthcare worker can access them.
The administrator of the system will always receive a flag when someone violates the protocol and access the secure information.
Because the data are recorded in digital format, there is no physical path or middlemen transporting documents, which a risk of losing them.
EMRs improve medical efficiency making access to information much quicker.
It contributes to rapid patient treatment, which can be vital in some time-sensitive situations.
For example, to perform and document an EKG nowadays you need only a couple of minutes.
Therefore, there are fewer delays caused by bureaucracy, which can affect the outcome.
The EMRs drawbacks
However, EMRs can lead to reduced oversight of clinical findings.
Any member of the healthcare team can simply click a button to reduce charting time, without actually interpreting the findings.
Overseeing even the smallest element of medical documentation can cause the entire medical record to be false.
If the workers are in a rush, there is a higher risk of mixing normal findings with the exceptions.
Investing in EMRs is expensive.
The initial costs for purchasing the software are high, and so is the staff education and system maintenance.
The next con of EMRs is possible technical malfunctions.
No matter how developed the technology is, there are still chances for malfunctions.
Therefore, paperback up records is still required when a system crashes.
After everything goes back to normal, you have to input the data in the system following the paper documents.
Sometimes, a system crash can cause delays in patients treatment or lead to the wrong decision.
To prevent errors caused by system problems, any healthcare organization should have guidelines on how to behave in these situations.
Additionally, the paper record should still be available and easy to access.
Another drawback is possible over-standardization.
Healthcare workers can face an unpleasant situation in which they need to order something that isn’t in the system.
For example, the medications or treatments that are not common can be excused from the official patterns, which can be confusing and promote errors.
The electronic way of storing data affects the interaction with patients.
Patients complain that healthcare workers often spend more time typing and looking into the screen than listening to the patient.
The consequences are de-personalization in care and even loss of trust.
Also, care providers sometimes complain about spending more time documenting than caring for patients.
Lastly, EMRs increase the work of any healthcare worker.
The duties of any nurse, for example, are enhanced with the need to fill out the electronic charts, handling emails, fielding test results in any day shift, etc.
For patients, communication with the healthcare worker is essential, but virtual communication increases the workload of any medical staff.
The EMRs are the future of medicine and healthcare.
With the sole purpose of improving security and safety, EMRs are a great tool.
However, EMRs come with a set of cons as well.