Electronic Health Record (EHR) The New Face of Healthcare

Electronic Health Record - The Biggest Contribution to Healthcare

Healthcare is taking one step ahead to manage the patient’s data electronically, which is necessary for the treatment of the patient as well as claim processing. Electronic health records and electronic medical records are the latest platforms used for data management.

What is a need for electronic intervention?

For best ethical practices, federal regulations are being implemented to every aspect of healthcare. Record management also getting structured under federal regulations and HIPPA compliance requirements. The tools used to capture the data and generate records are also expected to follow these regulations.

We have seen medical records generated on paper and in last few decades’ computer has replaced handwritten efforts to generate medical records to some extent, but required manual intervention for comprehension. But some basic limitations still persist:

1. Adhering to the data privacy and data portability rules by HIPAA is difficult
2. Data storage required more space and was tedious and costly.
3. Data assessing and accessing frequently was difficult.
4. It was a very time consuming process for the physicians as well.
5. There is no uniformity in the reports.

EHR Advantages:

Adhering to regulations is much easier with the help of latest digital platform. EHRs can create an environment that will provide much better solution and the service adds more value in terms of quality, cost effectiveness and preciseness.

Improvement in medical record generation as well as medical data collection with the latest technology based software helps the patients by improving their satisfaction level. Using EHR to capture data has following advantages:

• The data is easily recorded within stipulated time.

• There is a very minimal manual data comprehension required.

• The data collection errors are reduced to null.

• Data privacy is maintained.

• Data portability when required is safe.

•  Data analysis is far easier.

•  Record archival and re-utilization for treatment purpose is hassle-free.

This helps in collection of precise information in given time allowing doctors to spend more time for patient interaction and to focus on actual work. This has improved patient/physician relationship and the satisfaction in the patient.

ITCube provides solutions for converting scribbled handwritten documents to EHR (electronic health records). Domain expertise on board, resources with more than 10 years of experience in medical data handling and very sound knowledge of accessing different EHR/EMR makes ITCube the right choice for medical record generation via EMR/EHR.

Diagnostic Testing : Evidential Monitor of the Patient’s Treatment

Diagnostic Testing : Evidential Monitor of the Patient’s Treatment

Patient’s diagnosis is always supported by appropriate diagnostic findings and thus they become an inevitable part of the medical records. Physicians would like to review the past diagnostic findings on the patient, they do carry out different tests for confirming diagnosis.  These diagnostic results become part of the history and also can be a part of the physical findings and can be ordered as a part of treatment plan. Also there are separate documents generated for different studies carried out. 

Importance of Diagnostic Testing:

Diagnostic studies have immense importance in treatment of any patient. The results or observations from the studies are the prime source to confirm the diagnosis. They are used in

• Identifying disease, e.g. bronchovascular markings and patches seen on the x-ray can confirm the pneumonia based along with clinical symptoms.

• Identifying location of the disease, e.g. CT scans and MRI's are done on the patient to find out exact location of the tumor or injury deep inside the body.

• Classifying the diagnosis, e.g. anemia can be classified into its types based on the peripheral smear examination showing morphological differences in the blood cell structure.

• Monitoring the status of the disease, e.g. frequent lab tests like blood sugar, thyroid testing, cholesterol testing are done to evaluate the status of the disease.

• Monitoring the progress of the patient, e.g. Lab tests like electrolyte testing and BUN/Creatinine are done in dialysis patient to evaluate the kidney status.

• Finding causality of any complaint, e.g. for abdominal pain, abdominal ultrasound is carried out to find out if the gastrointestinal system, or urinary system or reproductive system or just muscular system is involved.

Types of Diagnostic Testing:

There are various types of diagnostic testing based on the technology used:

1. Laboratory Studies: This includes various tests carried out on body fluids like blood, urine, semen, CSF also faeces.
2. Pathological Studies: Biopsies.
3. Radiological Studies:  X-rays.
4. Imaging Studies:  Sonography, MRI and CT Scan.
5. Other Studies: Pulmonary function tests.

Diagnostic Testing and Medical Records:

Addressing findings in the medical document is necessary. Physicians many a times scribble these findings wherever they find place with short forms used and symbols used for their reference during patient encounter. Mentioning this data properly in the electronic health records is a challenge. If the numbers are missed, wrong units are applied or handwritten data is misinterpreted this can cause a big impact on the patient’s treatment process. Interpreting the data accurately in valid format with correct units if required is very necessary when we consider any diagnostic study data interpretation in the medical records. Of course, normally there are actual reports available to verify the data from medical records and they also need a proper interpretation when the data is considered for treatment.  Whom we can trust to interpret medical records including diagnostic data and diagnostic reports accurately?

ITCube Is The Right Option!!

ITCube is dealing with such types of records over a decade now. With team of medical experts on board and very large experience in managing medical diagnostic data and records, ITCube can process and rightly interpret 1000+ tests carried out frequently and very special tests carried out for unique cases. Meticulously interpreted and appropriately formatted diagnostic data helps medical professionals, lawyers and claim executives to treat the patient in more satisfying way. Medical data summarization can prove a complete solution to this.