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Recent technological advances have made it possible for each major hospital, clinic or doctor’s office to have their own, stand-alone, electronic medical records that summarize each individual patient’s medical history.

In most states in the USA, a medical office, by law, has to retain each patient’s medical records for at least seven (7) years. The ability to store medical records in an electronic format has great advantages over storing them in paper format, and both space and money can be saved by choosing to store records electronically. It is also far easier to update a patient’s medical records if they are stored in an environment where anyone who needs to can access them at the touch of a button. When records are computerized, they are also standardized, and gone are the days when new doctors or nurses cannot read older physician’s handwriting or understand their abbreviations.

Electronic medical records include not only questionnaires completed by the patient and his attending physicians but also all types of ancillary medical documentation like X-rays, ultrasound images and MRI images. Also, despite the fact that these records are stored by the hospital, clinic or doctor’s office, ownership still vests with the patient himself, and copies of the records must be made available to him whenever he requests them.

One of the few disadvantages to having a patient’s medical records stored in electronic format is that inappropriate people may be able to access private and confidential records. Within the standard hospital hierarchy, numerous healthcare professionals at every level have to access a patient’s records - from his physicians right down to the medical billing clerks - and care must be taken so that those without the necessary clearance are not able to access sensitive information. In the USA, medical privacy is legislated, and codes like the Health Insurance Portability and Accountability Act lay down what can and can’t be done with medical records.

Although it is presently practically possible for all hospitals and other healthcare facilities to utilize electronic medical records, not all facilities have opted to implement the required IT systems, and it will still take quite some time before all institutions become paperless.

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Q: The Advantages and Disadvantages of Electronic Medical Records?
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