Clinical Reasoning

Introduction

Electronic health records (EHRs), also known as electronic medical records (EPRs) or computerized patient records, are an evolving concept defined as the systematic collection of electronic health information about individual patients or populations. [1] It is a record in digital format capable of being Shared across different healthcare organizations by embedding into network-connected enterprise-wide information systems. Such records may include a range of data in aggregate or summary form, including demographics, medical history, medications, and allergies/immune status laboratories Test results Radiology images Vital signs Personal statistics such as age and weight and billing information.

Purpose

Its purpose can be understood as a comprehensive patient encounter record that allows for automation and simplification of health care processes and increases safety through evidence-based decision-making it contributes to quality management and results reporting.

Data Types

Definitions have been developed to describe the use of electronic systems for patient data collection. While these terms have been used interchangeably, each has a specific application [3];

1. Personal Health Record (PHR): Individual and individual accounts of medical history in digital form.
2. Electronic Medical Record (EMR): A provider-based system that encompasses all documentation for a patient related to all services provided within a facility.
3. The Electronic Patient Record (EPR): A patient-centered system that contains only patient records

These systems are organized around their technical capabilities to identify features of stored data such as quality and quantity such as;

• Medical imaging systems can store the raw data of the examination in any patient file
• Video recordings of surgical interventions or medical tests can be stored in configurable systems
• Internal memos and notes can be stored in their relative fields as text
• Correspondence with third parties (Doctors patients government agencies etc.) may also be used.
• Legal documents such as consent forms can be backed up and accessed digitally to ensure safe medical care

Electronic devices can be networked to provide automatic access and/or transmission of all these data types. Internet connectivity through secure networks will also allow buildings and organizations to connect.[4]

Role in Healthcare

EHR systems are used in a variety of ways in healthcare. A wide variety of applications exist such as systems for automating infectious disease alerts using existing data and mathematical formulas for public use in health care. Technological advances allowing new equipment to be used and improvements made to increase quality and efficiency. While research progress has been lacking in comparison to the rapid pace of technological discoveries over time, these discoveries exhibit tremendous potential to shape a robust and comprehensive framework for all health care services. [5] .

Role in Research

Electronic data systems can be used in clinical research environments to support the clinical research process. Institutions committed to research can benefit from a specific form of design documentation for clinical decision support and research protocol instruction sets. This approach can make it easier Comply with regulations while more easily creating cumulative and reusable data. This in turn could provide valuable large datasets to improve further research efforts. [6]

Security

The 2021 HIMSS Healthcare Cybersecurity Survey provides valuable information with the help of healthcare cybersecurity professionals responsible for day-to-day cybersecurity operations. The results of this annual survey will provide health professionals with insight and awareness to use electronic data system.

Key takeaways from the 2021 survey are as follows;

• Phishing is the most prominent malicious attack vector for these system health professionals, as their access is a prime target.
• These malicious attacks are often aimed at collecting information of financial value. Data with financial value should have higher security and access standards.
• During these attacks, these systems, on which some institutions rely heavily, may be disrupted. For such situations, contingency measures should be in place to continue providing healthcare services. [7]

EHR in Physiotherapy

Physical therapy services can benefit from electronic data methods. Attempts have been made to implement such systems, which paved the way for the specific design required for therapy. Telerehabilitation also speeds up the process due to its remote and digital nature. These systems can accommodate Exam diagnostic treatment plans and patient history data built around the ICF (International Classification of Functioning and Health). While the advantages are clear, there is still a need for general and security certification of these systems and the implementation at the current clinic. [8] A pilot study conducted to understand clinicians’ current attitudes toward these systems reported an urgent need for digital literacy motivation and an understanding of the benefits of electronic recording systems for physical therapists. [9]

The Future of EHR

Data collected through providers and researchers is growing in volume and variety. Funding constraints, legal hurdles, and ethical considerations are major issues to be aware of before electronic data collection evolves into a more important topic. this Technologies to process and analyze large amounts of data (big data) already exist and can yield results in many ways, such as genetic correlation of current data to discover new therapeutic vectors. [10]

The benefits of pursuing this endeavor are almost equal to the caution it requires, especially in the case of AI-assisted (artificial intelligence) analysis, which has the potential to reproduce the biases of its creators and impact the healthcare ecosystem in unpredictable ways . physical therapists can Greater involvement in research in the field.