The computer-based medical record: current status.

Area of Science:

• Medical Informatics
• Health Information Systems
• Clinical Documentation

Background:

• Historically, clinical records were not routinely maintained by hospitals or physicians.
• The paper-based medical record has demonstrated inadequacies with increasing societal and medical complexity.
• The transition to computer-based systems is driven by the need for improved data management and quality verification.

Purpose of the Study:

• To review the historical evolution of medical records.
• To highlight the advantages of computer-based medical records over paper records.
• To discuss the current trends and future of electronic medical records in healthcare settings.

Main Methods:

• Literature review of the historical development of medical records.
• Analysis of the deficiencies of paper-based records.
• Examination of the decreasing barriers to computer-based record adoption (hardware affordability, software refinement).
• Discussion of societal and payer demands for quality and effectiveness verification.
• Case study of computer-based clinical record systems in two family practice settings.

Main Results:

• Computer-based medical records address many deficiencies of paper records.
• Decreased hardware costs and improved software have reduced barriers to adoption.
• Electronic medical records can enhance care quality through decision support and data for research.
• Standardization efforts are underway for computer-based medical information systems.

Conclusions:

• The electronic medical record is a crucial step in the evolution of clinical documentation.
• Forces such as technological advancement and payer demands are driving the computerization of clinical records.
• Computer-based systems offer significant potential for improving healthcare quality and efficiency.