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Top2. The Milieu
The Australian Standard AS 2828 pertaining to paper based health care records (Standards, 1999) define that a health care record is the primary instrument used to document the evidence of care provided now and in the future. It also provides a means of communication to other health care professionals. The methods of collecting and storing health information has transitioned from paper, to microfilms and further taken on new electronic forms (Bailey, 1997). The paper based medical record which was established within the hospital system in Australia, has evolved with varied influences including changes in clinical practice, statutory obligations, Standards Australia, Professional Colleges and Associations (Carine & Walker, 1997) and in recent years, with the pervasive power of ICTs (Ludwick & Doucette, 2008).
Scanning technology is being used to build computerised patient records or CPR, as the first step of digitisation, towards transitioning into an Electronic Health Record or EHR (Chin, 1999).
An electronic longitudinal collection of personal health information, usually based on the individual, entered or accepted by health care provider, which can be distributed over a number of sites of aggregated at a particular source. The information is organised primarily to support continuing, efficient and quality health care. The record is under the control of the consumer and is stored and transmitted securely. Health Information Network for Australia (HINA) report (NEHRT, 2000)
The Medical Records Institute has developed five different levels to explain the automation process in the transition towards an EHR (Lewis & Mitchell 1998, p. 31), better known as the five levels of automation (Table 1) in the transition towards a fully Electronic Health Record system.
Table 1. Levels of automation in the transition towards an HER (Lewis & Mitchell 1998, p. 31)
| Level | Characteristics |
One:
Automated Medical Record | • Relies on input from paper based documents
• Doesn’t alter the paper based system |
Two:
Computerised Patient record (CPR) | • A system that stores already paper based documents into digital format through a scanning system.
• Record can be accessed by more than one person at a time
• Requires indexing of data |
Three:
Electronic Medical Record (EMR) | • Direct input into the computer by users
• No paper back up
• Increased integration of data, for example pathology |
Four:
Electronic Patient Record (EPR) | • EMR with multi provider, multi sites links (e.g., General Practisers)
• Requires infrastructure and technologies for information interchange |
Five:
Electronic Health Record (EHR) | • EPR with non traditional health and lifestyle related information (e.g., Aromatherapy)
• Health Information for whole well being of the individual |