Benefits of Electronic Health Records

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One of the major challenges facing the Information Society today is, without doubt, the Benefits of Electronic Health Records. A doctor can have all the information generated by a patient over their lifetime, regardless in many centers or how localities have been treated, and that all such information is available in seconds, is one of the great challenges of any advanced society. However, we are talking about a goal of enormous complexity whose achievement is neither simple nor quick for several reasons. One of the most important undoubtedly refers to the storage of information. The benefits of Electronic Health Records involves, among other things, that all the information generated by a patient is not only stored but can be retrieved at any time in an almost immediate term.

This requires filing any information produced by or for a patient, ie, from the notes taken by the doctor in an outpatient to sophisticated medical tests for a patient to undergo, without forgetting results blood tests, x-rays, ultrasounds, or mammograms, to name just a few.

The Benefits of Clinical history

Clinical history (CH) is the key element for professional practice of health as it is the only document in which you write and all patient data are orderly, chronological and are guaranteed by the respective firms professionals and authorities, as well as institutional distinctions of the various parts of the HC. It is useful not only from the standpoint care, it acts as a reminder for the clinical management of the patient, and from the health researcher and teacher of different health specialties, allowing retrospective analysis of professional work.

The electronic health record (EHR) is one in which information above with respect to the HC is captured electronically, digital, computerized, that is to say that paper and pen is not used but is recorded with a keyboard or directly with the voice of the intervening professional. The support where it is written is "electronic" in all its forms: hard drives, compact disks, optical disks, diskettes, tapes and many more, that will develop in the future.

Profile of the Electronic Health Record(EHR)

The history is not a notarial document. No doctor uses medical history to record everything that has happened in the query. In the clinical history only the relevant information for monitoring the patient is recorded. Although clinical care is what supports and generates history, it has other applications in management, evaluation, planning, training, research and medical-legal aspects.

The annotation history can identify a patient:

- Requested professional services, on its own initiative or a third party in a given time and place,
- It was attended by a particular professional, who identified one or more health problems.
- Started a logical process of care aimed at resolving or mitigating the consequences.

The use of a well designed, machined history will increase public longitudinality, continuity, quality, health outcome and wise use of resources. Longitudinality through better vision of all the health problems of the patient and family (personal and family longitudinality) to help it develop and strengthen the personal relationship between doctor and patient. Continuity, through monitoring of events constituting an episode of care, including those that occur outside the health center. Quality, facilitating continuous auditing of medical care provided to the patient beforehand, relating it to the attention of other patients and the scientific information from the literature.

To store data in electronic medical records

Social Data:

Social data are those that allow placing the patient in society; are other identification data. The identification are:

- Name.
- Date and place of birth.
- Apparent Sex with which the patient is identified.
- Number of national identity (and perhaps, Social Security number and medical record number).

Preventative data:

In a broad sense, all clinical preventive activities as it seeks to eliminate or reduce the damage caused by the disease. However, physicians include specific preventive activities among those performed regardless of the control of a specific disease. Thus, specific preventive measures include:

-Infections: tetanus, rubella, pneumonia, hepatitis, diphtheria, meningitis, tuberculosis, chickenpox and others. The field is changing, and depends on the age and sex of the patient, the decisions of health authorities and the evolution of technology.

-Cancers: breast, cervical, colon, lung, skin and others. Field Eneste how important are age, sex, lifestyle and family history. For example, recommended biannual mammography in women aged 50-65 years, the council against snuff in smokers. Applications and concrete decisions are subject to discussion and highly dependent on the prevalence of disease in the reference population.

-Chronic diseases: early detection of hypertension, dental caries, of retinopathy in diabetics, osteoporosis and other diseases. In these cases are critical age, sex and underlying disease. In this area clinical and preventive care are mixed, and depends heavily on the outcome of the ongoing investigation.

- Life Habits: addiction, birth control, nutrition, exercise and others. In this case involves both prevention (to prevent the disease and its consequences) and health promotion (promotion of healthy lifestyles). For example, treatment with contraceptives requires certain controls but prevents unwanted pregnancy and therapeutic abortion, and easier to maintain a healthy sex life.

- Genetic Diseases: cystic fibrosis, Huntington's disease and others. The difficulty in this group is the lack of scientific evidence.

-Complications Pregnancy and childbirth: gestational diabetes, meningocele, Rh incompatibility, neonatal tetanus and other. Preventive guidelines should be adapted to the characteristics of pregnant and personal and family history of both parents; rely on scientific evidence, technological capacity and health policy.

- Other preventive guidelines: monitoring of healthy children, scoliosis in adolescents and others.

Other benefits of Electronic Health Records:

Availability
The Electronic Health Record is usable in all times and places. The manual is always usable in one physical location. Any professional anywhere in the world could access it previously identified with a unique access key.

Accessibility
The EHR is always available. Usually manual sometimes lost. The EHR will be updated on-line and accessible at the time of consultation with the professional.

Confidentiality
Will have access only those who have the "key" to enter the same and the same rules of medical confidentiality will continue to support that role. Furthermore not only be restricted access to the full story in the case of strangers to it.

Security
Inviolability: Using encryption techniques to prevent alteration of medical records through the development of a software.
Sequencing: The program prevents the update sequence is altered.
Alterations by third parties: If passwords are used adulteration of EHR is avoided.

Readability
It is quicker to read and understand the stored data.
The EHR is always legible. The handbook, we know, is unreadable in most cases.
Duration: copies are made to CD or optical disc new generation that ensure durability over time.

Legal value
If the appropriate software package is used, the data will be encrypted and would not lead to unintentional errors, for which would have full legal force of law and fact.
Portability and Printing: The patient may have a copy of the CH, through a paper or CD, pen-drive or other device.
Recoverability: You can retrieve the information from professionals, not erasing the historical and current record keeping sequentially.

Chronology
The ERH is always full, with date and time of events. Manual sometimes with date and time are not exact, when they do.

Electronic signature
The EHR is always signed by the professional who evolves. The manual is not always signed.