Patient medical records are perhaps the most vital component when providing comprehensive, evidence-based care to those in need. Without an EMR (electronic medical record) system, healthcare experts would be left in the dark. Naturally, one might presume that EMRs serve to remain accessible, accurate, and interoperable at all costs. If this proves to be the case, how are preventable medical errors the third most common cause of death in the United States?
Claiming the lives of over 400,000 patients each year, a medical error is defined as an “adverse effect of care [caused by] an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.” 1, 2 Although this can be attributed to a variety of potential causes throughout the healthcare pipeline, EMRs stand as the primary suspect.
Basic Expectations of an EMR
In order to act as a reliable method of storage for patient information, EMRs must adhere to a lengthy set of needs comprised by healthcare data regulatory bodies and medical professionals themselves. Ideally, an EMR software for best practice management should:
- Safely store patient data of varying mediums (eg. text, images)
- Organize information in such a way that promotes accurate documentation over time
- Adhere to all GDPR and other privacy regulations
- Connect with other medical software for the seamless transfer of data
- Allow medical professionals to communicate and privately share patient data
The Status of EMRs
Only by adhering to these basic criteria may a dermatology-based EMR software adequately support a practice in their goal of providing accurate, evidence-based care. Unfortunately, the majority of systems fail to meet the needs of medical professionals, as they are out of date, lack scalability, are not interoperable, or simply promote unreadable data (defined as information that isn’t “understood” by the system, such as handwritten notes). As a result, medical professionals are forced to rewrite patient files (resulting in duplicate information or incomplete halves of a profile), repeat questions to patients, and continue the risk of losing what little patient data to which they can access.
Building on this concept, many systems fail to the interoperability test, meaning that data cannot be properly transferred between systems. For example, if a patient visits their primary care physician for the examination of a skin spot, they will likely be referred to a dermatologist. However, if that dermatologist’s clinic utilizes a different EMR system, the patient’s record cannot be transferred. Furthermore, if a pathology sample is requested, a third variation will be created by the pathology lab- with each rendition containing different vital pieces of information.
After identifying these intrinsic flaws within the healthcare system, it becomes clear as to why patient charts cannot be located on 30% of visits.1 Before a dermatology EMR software can support its users, it must first ensure it addresses the needs of the practice. Although criteria will vary, at its core all systems must remain scalable, connected, and secure. If patients are to receive comprehensive care, this must begin with providing dermatologists and other medical experts with the tools to properly document and utilize this indispensable information.
-The MetaOptima Team
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