Computerized Medical Record Software

Electronic computerized medical record systems are computer-based patient medical records. Doctors’ offices and hospitals throughout the United States are increasingly using them because they offer certain advantages over conventional paper-based medical records. Such computerized medical record systems are also useful in processing health insurance claims and following up with patients. The most important benefit to medical providers is the instant availability of data once it is entered electronically, and the space and labor savings resulting from the elimination of paper-based records.
Electronic computerized medical record systems are readily accessible, increasingly standardized for seamless use where and when required, and greatly reduce the likelihood of error in either entry or interpretation of medical information. Having access to a patient’s medical and contact information readily available can be potentially life-saving during critical medical events such as severe allergic reactions or heart attacks. By reducing errors and saving time, a computerized medical record may therefore help reduce the large number of deaths attributed to medical error in the United States each year.
The physician named Lawrence L. Weed was the first to describe the concept of computerized medical record or electronic medical record. He described a computerized medical record system to automate and reorganize patient medical records in order to enhance their utilization and therefore to improve patient care.
His work later formed the basis of the PROMIS project at the University of Vermont. It was a collaborative effort between physicians and information technology experts that started in 1967 to develop a computerized medical record system. The aim of the project was to develop an automated or computerized medical record system that would provide the physician with timely and sequential patient data and to enable a rapid collection of data for epidemiological studies, medical audits and business audits. The group’s efforts to produce a computerized medical record system led to the development of the POMR, or problem-oriented medical record. The Mayo Clinic also began to develop a computerized medical record system in the 1960s.
The POMR was used in a medical ward of the Medical Center Hospital of Vermont in 1970; by that time touch-screen technology was introduced into the data entry procedures. Over the next couple of years, elements regarding drug information were added to the core program, thus allowing physicians to check for drug actions, side effects, dosages, allergies and interactions. Meanwhile diagnostic and treatment plans for over six hundred common medical problems were devised.
During the ’70s and ’80s several computerized medical record systems were developed and refined by many other academic and research institutions. Systems like the Technicon system which was a hospital-based computerized medical record system, and Harvard’s COSTAR system had records for ambulatory care. The HELP system and Duke’s ‘The Medical Record’ are amongst the early in-patient care systems. And Indiana’s Regenstrief record was one of the earliest combined in-patient and outpatient systems.
The rapid advancements in computer technology and diagnostic applications during the 1990s, led to computerized medical record systems that were increasingly complex and more widely used by practices. In the 21st century, more and more practices are implementing computerized medical record systems.
As computerized medical record systems are more widely used, concerns regarding the protection of patients’ confidential medical information and privacy have increased. In 1996, the US Congress passed the Health Insurance Portability and Accountability Act (HIPAA), and a more stringent Privacy Rule went into effect in 2003. HIPAA sets required national standards for medical records, guarantees patients the right to see their own medical records, and requires providers to inform patients how their medical information is used and disclosed.