Computer and its uses in Medical Records Management
Introduction
Handling of information through technology has become in recent years, a science in itself. Information science in everyday life is springing up as a new business which is devoted entirely to meet the needs of management and scientific groups in establishing better systems for storing and retrieving information. The current HMS (Hospital Management System) is the outcome of transformation that has taken from the manual hospital related information management to a fast and accurate computerised HMS and promises to play this role even more dramatically.
What is a computer?
A computer is a device that accepts information (in the form of digitalized data) and manipulates it for some result based on a program or sequence of instructions on how the data is to be processed. The components of the computer is, a) Keyboard, b) Data Storage Devices, c) The Optical Disk d) Printer e) Mouse
Key board
A keyboard is basically a board of keys. Along with the mouse, the keyboard is one of the primary input devices used with a computer. The keyboard's design comes from the original typewriter keyboards, which is arranged with letters and numbers in a way that prevents the type-bars from getting jammed when typing quickly.
Data storage devices
This device stores information on a long-term basis. There are two types of data storage devices internal and external. The storage devices are Hard discs, optical disc etc.
The optical disk
The microcomputers have developed optical disks in recent times called as CD ROM's or Laser disks. These disks use a laser to write data onto a hard magnetic platter. This is similar to the technology used to record sound on a compact audio disk.
Printer
Printer is a device that translates signals from a computer into words and images onto paper in black and white or color. Printer types include dot matrix, ink jet, laser, impact, fax, and pen, plotters and ink devices.
Mouse
The mouse is the cursor control device, by which many operations of the computer can be performed by clicking.
Software
The software refers to the medium containing the information that instructs the hardware how to perform a particular task. Coded instructions (programs) make a computer to do useful work.
Program
A program is a set of instruction written in various computer languages or an application program for performing a task. This prescribes the actions ("computations") that are to be carried out by a computer. Most programs consist of a loadable set of instructions which determines how the computer will react to user input when that program is running, i.e. when the instructions are 'loaded'.
Operating system
There are three types of operating systems- Micro Disk operating system (MS-DOS), Microsoft windows (MS-Windows) and the UNIX operating system. The Microsoft-windows is the commonly used operating system in the personal computer. The network version is also used in Local Area Network computers.
Application programs
A program that performs tasks is called an application program. For example, a word processing program is an application program that inputs, edits and prints documents such as letters, memos, and reports. Excel is an application program that manipulates numeric data, related to inventory or financial analyses such as inventory of a store or hospital statistical analysis
Word processor (Microsoft word)
A word process is a program for manipulating text. Such programs allow you to type a document and alter it on the screen as you type. You can move directly to any point within the document to add, delete, copy or move a section of text, incorporate pictures, and import information from other application programs.
Spreadsheet (Microsoft excel)
An excel program turns the microcomputer into an accountant's worksheet. It can be used to plan budgets, to do accounting tasks, and to analyse investments. This program allows defining relationships between numbers with the definitions and formulae of the hundreds of numbers entered on the Excel can be manipulated to required data.
Database management (Microsoft access)
Database is very important for any organisation. For example, there is a data sheet in the patient's information and the laboratory generates an investigation report for every order placed. These information data can be easily maintained by storage in a diskette. When necessary, such data can be analysed or updated by using the database management program, Microsoft Access.
Graphics
Graphic programs help in creating images on a screen and to print such images with a printer or plotter. The most common graphics are bar charts, line graphs, pie charts, and histograms.
Computers and communication
Communication and computers have become easy and fast. With the online system and Internet facilities, computer users all over the globe are able to communicate with each other via electronic mail and with minimal cost. The hospitals of different parts of the world want to share their medical technology through the Internet facilities or telemedicine facility. This has facilitated the storage of research work information on the World Wide Web, which is used all over the world through Internet facilities.
E-mail (Electronic mail)
Electronic mail is one of the communication programs. By electronic mail one can receive memos, reports, and sales information from anywhere in the world. The sender can deposit the mail at any time, and you can view your mail by using a communication program to transmit the mailbox to your computer. You can also down load and print.
Development of computerised medical records management system
- The development of computerisation in the field of medical records was started in early 1960's by storing the patient demographical information, which was retrieved as and when necessary
- The clinical information including diagnostic and operation indices is also stored separately. This has reduced the manual work carried out for the statistical purpose
- Each department- medical, surgical, laboratory, radiology, wards, administration is equipped with personal computers, which operates individually, hence when information was required from a particular department, the information was retrieved from that particular computer.
- The invention of the Local Area Network (LAN) and Wide Area Network (WAN) have enabled individual computers to be linked with the help of a central server. This type of networking system made the data available at any part of the hospital where the computers are connected to the central server.
- Even the health care organizations, which are geographically located in different areas are linked through the telephone lines by a modem. This has considerably reduced the time necessary for retrieving information, within and outside the health care organization.
- One of the important recent developments in the field of computers is the scanner. The technology of the scanner is the same as the photocopying machine, but the image scanned is stored in the electronic medium.
- The scanned images can be further magnified and viewed or printed for the clarity and clearness of the findings.
- This technology in the field of the medical record has eased the process of retention of inactive records by scanning and storing them in the electronic medium.
- This has also paved the way for the Electronic Patient Record, as almost all the clinical information including the diagnostic results can be scanned and viewed through the monitor
- Instead of physical records, now records are documented by typing the information straight into the computer and diagnostic images scanned and stored to be available online. Once the information has become inactive, it will be stored in the secondary storage device for future references
Advantages of computerised patient's clinical record
- Good medical care requires comprehensive and accurate records than previously due to advancement of technology, high expectation of patients, malpractice, third party payer's claims, and enormous cost to provide efficient health care.
- All these lead to effective methods of keeping the patient's clinical records.
- The computer system must accomplish something better than the manual medical records and help the physicians, nurses and other staff to improve their efficiency in providing better medical care to patients with reasonably low cast.
Telemedicine
The Tele-medicine is nothing but, the transfer of the health information from one part of the world to the other to get the experts opinion for further management of patient care. With the latest development, the management of health information can also spread in the remote areas by having a wide area network, in which the information can be stored and shared from a central server to any part of the world.
Electronic medical records (EMR)
The paperless medical records can be defined as the patient care management data entered directly or infused into an electronic machine which is capable of accepting, storing, and retrieving comprehensive integrated data in the least possible time at the required places. To achieve this, there is a need to design clear patient care management information, which should assist in registration of total patient information at the point of each transaction.
The capture of data is recognised to be a key concern in designing a comprehensive Health Information System (HIS). Maximum benefits including improved quality cares with reduced cost are only realised when the primary creators and consumers of information interact directly with a system.
Computers offer "on line" systems that provide the hospital staff with direct access to computerised data bases through decentralised communication terminals. Ideally the computerised system for medical records should be integrated with the hospital information system. Some of the advantages of EMR is that the records are organised, legible and, therefore, likely to minimize misunderstandings as well as patient care errors. The health care professionals especially nurses, are more productive as less time is devoted to paperwork and also instant billing is possible.
Summary
The health care delivery system is rapidly changing due to the high expectations of the society. The general public has become increasingly interested and knowledgeable about health care and health maintenance. The strategy of health care delivery system has to be completely reorganised in view of the fast growing technology which is available to the human being today. In order to improve the traditional health care system, a computer-based medical record should replace the traditional paper record. The challenges of migrating to the modern technology like computer-based health information, intra and internet linking systems are enormous, but, so are the rewards.
In conclusion, the manual system had served the purpose of the hospitals. With advent of the computer technology unwanted costly and duplicate system has been restricted. As manual system leads to duplication and more clerical efforts and time consuming and needs extra efforts to achieve certain results. In manual system there is more expenditure, and also possibility of losing the health information due to the environment factors such as heat, rain etc and also due to human error such as misfiling or not keeping an account of records not returned.
Key points to remember
- A personal computer is a single device which consists of a number of separate components that work together as a microcomputer system
- Keyboard consists of various keys that allow the user to input data, control cursor and pointer locations, and to control the dialog with the workstation.
- The two types of data storage device are internal data storage called the hard disk, which is a built-in part of the computer and external data storage devices which included floppy disks, and CD-ROM diskettes.
- The optical disk uses a laser to write data onto a hard magnetic platter.
- Printer is a device that translates signals from a computer into words and images onto paper in black and white or color.
- The physical components of a microcomputer system are collectively called as hardware.
- Software refers to the medium containing the information that instructs the hardware how to perform a particular task.
- A program is a set of instruction written in various computer languages or an application program for performing a task.
- By using Electronic-mail the sender can deposit the mail at any time, and the receiver can view the mail by using a communication program to transmit the mailbox to his/her computer
Student exercise
Answer the following
- Explain briefly about various parts of the computer with examples.
- Write short notes on microsoft office and explain how it is useful to the staff of medical records.
- What is the work of a printer? Mention the common types of printer and explain how it is useful to the functions of medical records?
- The recent trend of using HMS (Hospital Information System) software has emerged most probably in all the hospitals. How this will be useful to your hospital?
- The health care system is rapidly changing with new innovations to change the entire medical records to a paperless office. Explain how this will be possible and the benefits thereafter?
