Making the move to a paperless practice has equal benefit for both your practice and your patients. However, because patients often have a limited understanding of what a paperless practice means for them, it is important for you to engage your patients in a conversation around health information technology, and in particular their electronic medical record (EMR).
Fortunately, the majority of patients who are insured with either Discovery Health, Medscheme or Metropolitan, will be familiar with electronic records and may already have granted you access to those records. However, not all patients will know about the benefits of EMRs.
We’ve answered a few EMR FAQs to help you have an informed discussion with patients about the kind of information that gets stored, whether it gets shared and with whom, and how they can use them to improve their health and wellness.
Patient EMR FAQs answered
What is the difference between an PHR, EMR and EHR?
Patient or personal health records (PHRs) is information that you keep about test results, reports and your treatment. PHRs can also be used to schedule appointments and monitor your health by tracking metrics like weight, body mass index (BMI), how much you exercise, blood sugar levels, cholesterol tests and more. EPRs allow you to upload documents, prescriptions and notes. Making this information available to your doctor can optimise (and personalise) the care you receive.
Electronic medical records (EMRs) are a digital version of the clinical notes that your doctor makes when you visit the practice. Typically only that doctor has access to those notes unless you have given consent for your records to be shared with other doctors as part of your treatment. An EMR contains a patient’s medical history, diagnoses and treatments by a particular physician, nurse, specialist, dentist, surgeon or clinic. This information remains with the practice and will not be shared, except possibly with other healthcare professionals who are treating you, or with your medical aid if you give your informed consent.
An electronic health record (EHR) is also a digital version of a patient file, but is a broader view of the patient’s medical history. EHRs include much more information about your entire medical history, such as hospital stays. Electronic health records are designed to be shared with other providers, and allow authorized users to instantly access a patient’s EHR from across different healthcare services. You can consent to sharing this information with your doctor to help them optimise and co-ordinate your care.
Why does storing my medical record digitally matter?
Securely storing your EMR is important for a number of reasons, including keeping a reminder/record of important information that could otherwise be lost. For example, EMRs enable your medical practitioner to:
- Store you and/or your family’s medical histories
- Have a record of what medications you are taking, the dosage, any previous side-effects of medication and allergies
- Store the results of any laboratory tests, such as blood tests, radiology reports, scans, and any investigations into your condition.
- Discuss your medical scheme benefits and how the consultation will be covered.
Having this sort of information available and up-to-date can help your doctors provide the best possible care.
How can an EMR benefit me?
- Better care: Your treating doctors are able to offer your better care coordination if they have access to the same, up-to-date information. This means less duplicate tests, lost results, data capturing errors, etc.
- Better diagnosis: More complete and up-to-date information means more accurate diagnoses.
- Better communication: Using EMRs, prescriptions or doctors notes are printed and/or emailed reducing the likelihood of interpretation errors or losing important information (and no more deciphering illegible handwriting). EMRs are also used to send SMS reminders from the practice about your next scheduled appointment or annual health screenings.
Does an EMR store my patient information securely? Is my information safe?
Electronic records of any nature, be it health related, financial or otherwise, is valuable to cyber criminals. But professionals or organisations that store digital information is legally obligated to take reasonable measures to ensure that information is kept securely, and not shared or leaked unlawfully.
The National Health Act makes it an offence for anyone to share your information without your consent. The only exceptions are when the law or a court order requires disclosure, or if non-disclosure represents a serious threat to public health.
In terms of the Protection of Personal Information (Popi) Act, an entity and all its employees are obligated to treat all personal information as private and confidential and they may use the information only for purposes they disclose to you when collecting the information.
When should I give consent to access my electronic medical records (EMRs)?
According to the Popi Act, you should be told about the kind of information being stored about you, how and why it might be shared, and with whom. Giving consent to your doctors, medical schemes and other providers is one way to ensure that you are enabling the best possible care for yourself but it must be informed. In other words, you have had a frank, informative discussion with your providers to ensure that you understand what you are agreeing to.
Speak to your doctor or medical aid for more information about your electronic medical records and how you can use them to improve your health.
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