You may have noticed huge filing cabinets full of strangely colored and numbered charts at your doctor’s office. These are paper charts stuffed full of hand-written information about patients, their lab results, treatment plans, consultations, and more. More often then not, they are written in the bizarre chicken scratch of physician handwriting which even other doctors find difficult to decipher. A missed decimal point, a difficult to read medication, or simply misplaced information are far too common problems with this approach to medical record keeping.
There is a revolution underway in health care. New standards for Electronic Health Records are (slowly) doing away with the paper chart. Electronic Health Records (EHRs) are revolutionizing the way health care providers manage complex health information. Most importantly, these improvements in medical record management are leading to real improvements in patient safety.
Medical information about patients, their test results, plan of care, medications, orders, and treatment plan can now all be inputted into mobile tablets where it is instantly available on demand to providers involved in the care of the patient.
One example of how electronic health records improve safety is in automated drug interaction analysis. Drug interaction occur when two medication interact to cause potentially serious side effects that neither drug would have likely caused if taken alone. Physicians simply are unable to keep track of every drug interaction in their head which unfortunately was pretty much how we practiced medicine before the advent of computers. Let’s look at the common pain medication, Ultram. Ultram (also known as Tramadol) has *741* known drug interactions, 368 of which are considered to be major drug interactions. There is simply no way any physician with even the most remarkable memory could recall them all. This is one major way that electronic health records help to reduce medical errors: a computer can check the patient’s entire drug profile and spot interactions as well as to prevent the prescription of new drugs that may cause interactions.
Are you curious to check for interactions of the drugs you take? Try this drug interaction checker online. What you find may surprise you! Drug Interaction Checker
EHRs reduce the likelihood of making errors, improve patient safety, and improve patient outcomes. Physicians can access prior visit history with the touch of a button and access critically important information for a patient with a serious or life-threatening condition. Complicated information including laboratory results, x-ray and CT scan reports, EKGs, vital signs, and patient status can all be aggregated into the record in real time. We used to rely on the laboratory to print laboratory results on papers that would end up shuffled all over our desks from multiple patients. The chance to make mistakes in this scenario were all too real. Now the patient’s results are added automatically into the electronic health record where they can be reviewed more reliably.
Data security is a key feature of electronic health records as well. Government standards for securing Patient Health Information (PHI) exist under the HITECH act and guide the security of our patients’ medical information. All the same rules of privacy apply to electronic health records under HIPAA, the federal government rule that protects the release of medical information to third parties.
Code 3 takes patient safety and efficiency of care very seriously. That’s why all Code 3 facilities use only electronic health records in managing the patients in our care. Our laboratory, radiology, patient records, front desk, and really all aspects of our record-keeping is fully electronic. X-ray reports from radiologists, test results from the laboratory, orders from the doctor and notes from the nurses are all automatically integrated into our electronic medical records to improve safety and deliver fast efficient care!