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The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for ...
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
Theoretically, free software such as GNU Health and other open source health software could be used or modified for various purposes that use electronic medical records i.a. via securely sharing anonymized patient treatments, medical history and individual outcomes (including by common primary care physicians). [46]
Electronic medical records, like other medical records, must be kept in unaltered form and authenticated by the creator. [24] Under data protection legislation, the responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility.
Dividing his time between research, patient care and teaching, he developed a method which reorganized the structure of the medical record from being divided into the different sources for patient records (x-rays, prescriptions, physician notes) to one structured around a well-defined list of a patient's medical problems. [3]
Furthermore, the importance of quality department leaders has been stressed in order to make sure the electronic medical records system is beneficial in providing quality care. [5] Hospitals have been using different suppliers of health data systems in order to adopt electronic medical records.
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
The European Health Data & Evidence Network (EHDEN) is building a data network to perform fast, scalable and highly reproducible research. According to their website, the goal is to standardise 100 million patient records across Europe from different geographic areas and data source types, such as hospital data, registries and population databases.