The electronic patient record in the Brazilian health system: is it a reality for physicians? <b>[Abstract in English]<\b>

Abstract

Aims: To conceptualize Electronic Patient Record, and to discuss its advantages and disadvantages, the importance of its implementation in medical and hospital services, the ethical aspects involved and the challenges for the medical use of this tool, in order to support decision making about the use or nonuse of Electronic Patient Records in medical practice. Source of data: Scientific papers, PhD theses, dissertations and web sites. Following databases: Medline, LiLACS and Google Scholar. Keywords searched: medical records; electronic medical records; information systems. The research conducted between December 2009 and August 2010 identified 300 abstracts. Forty-six papers, intrinsically related to the purposes of this paper, were selected to be read in full. Summary of findings: The Electronic Patient Record can optimize the physician’s work, because it allows faster access to patient information, can document the services rendered throughout life, and provides legibility of the data and integration with other information systems. However, difficulties in its implementation are also reported, especially with regard to ethical aspects, lack of standardization between the systems and handling of software. Conclusions: Despite the difficulties reported, we believe that is extremely important to create information systems that include Electronic Patients Records in the Brazilian health system in order to identify users, facilitate the management of services and communication, sharing information and, most importantly, to improve the quality of care provided to the population.