Title

Electronic medical record

RIS ID

90679

Publication Details

Miller, A. Andrew. (2014). Electronic medical record. In G. Starkschall & R. C. Siochi (Eds.), Informatics in Radiation Oncology (pp. 37-48). Boca Raton, USA: CRC Press. http://www.crcpress.com/product/isbn/9781439825822

Link to publisher version (URL)

Informatics in Radiation Oncology

Abstract

Radiation oncology informatics is an area in its itifancy. Although radiation oncologists will agree with the importance and primacy of patient data in the evidence-based medicijle era, the reality of their patient's electronic medical record (EMR) data may not mirror this appreciation. Most departmentb have an EMR, but few would be able to produce an accurate "handsoff" clinical report, that is, a database report that details a Jatient group based on diagnosis, stage, treatment, and details outcomes without physically looking inside a patient's record. The. EMR details the patient's radiation treatment parameters consi~tently and in fine detail but only because these data are entered "religiously" and are repeatedly quality assured as the basis for safe radiotherapy by a group (dosimetrists and therapists) whd work intimately with this data. Why should the diagnosis and stage data be of a lesser quality? Simply because medical stalf frequently do not to enter these data in the allocated places with the result that it cannot be used for reporting. Whether this is due to choice, thinking that stating it in a dictated notation ls sufficient, or being forced by well-meaning bureaucrats to enter the data in a separate system, the reasons for this failure are numerous (Lapointe & Rivard 2005). Irrespective of reason, the result remains the same: the medical data of millions of patients seen and treated in radiation oncology departments are not available for systematic aggregation and analysis. Yet, radiation oncology is one of, if not the most, suitable medical specialties for an informatics approach.

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