What is an Electronic Patient Record?

An electronic patient record is a file kept on a computer that keeps vital information about the patient's current health and history. In the past, patient records have been largely kept as hard copies in physical files, often seen in the receptionist area of doctor's offices. In the United States, many offices, clinics and hospitals are converting to an electronic medical record system in anticipation of possible mandates from the U.S. Federal Government.

There are a number of reasons why the government is encouraging moving patient records from physical files to electronic format. Electronic patient record files are easier to transfer, there is no confusion over poor handwriting, for which some doctors are notorious. There is also a general efficiency that can be realized, thus possibly leading to a cost savings for both the patient, and the medical provider.

A doctor, for example, can access a computer in the treatment room, and look at all vital and relevant information on the electronic patient record before rendering a diagnosis and prescribing treatment. He or she can then put a prescription directly into the computer, which will not only log that the patient is now on that medication, but also is capable of immediately sending the order to the patient's pharmacy of choice. Thus, steps are saved and there is no need to worry about misplacing a file.

If an emergency physician needs access to a patient's medical history, and a doctor's office is not open, an electronic patient record may be available immediately. This assumes the hospital has access to the same database that the doctor's office uses. This could save lives by ensuring that an incapacitated patient is not given a drug he or she is allergic to, or which reacts negatively with a medication the patient is already receiving.

While these benefits are all good, there are also some negatives associated with the switch to an electronic patient record. If, for example, the doctor's office database is accessible by other institutions, there could be some concern that someone unauthorized could access the record for illegitimate purposes. While this could happen with physical files, the potential for abuse with electronic files is greater, because there is more opportunity for more people to access them, and the information can be moved, analyzed, and sold much more rapidly. Additionally, electronic files, by their nature require access to a computer, which, in turn, requires electricity. Thus, during a natural disaster, when electric power may be unavailable, the records also would not be available.

Another possible negative is finding a uniform standard that everyone agrees on. Much like there are two major computer operating systems competing against each other, Microsoft® and Apple®, there is also no nationally-recognized standard for an electronic patient record. In order for the system to work seamlessly, the software must be uniform, or there must be a way to convert among different standards easily.