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Standards and Guidelines for Electronic Medical Record Systems in ...

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Cl<strong>in</strong>ical Decision Support<br />

This refers to functions <strong>and</strong> processes that assist health workers <strong>in</strong> mak<strong>in</strong>g cl<strong>in</strong>ical decisions to<br />

enhance patient care.<br />

EMR <strong>Systems</strong> are required to:<br />

i. Highlight abnormal test results<br />

ii. Alert provider of abnormal (outside the normal range)vital signs<br />

iii. Alert provider if a known allergic drug is prescribed or if a known drug <strong>in</strong>teraction is<br />

likely to occur<br />

iv. Provide rem<strong>in</strong>ders of recommended care due such as tests due <strong>and</strong> medication due<br />

Order Entry <strong>and</strong> Prescrib<strong>in</strong>g<br />

Order entry is the process by which a health care worker electronically enters <strong>in</strong>structions <strong>for</strong> the<br />

care <strong>and</strong> treatment of patients under his or her care.<br />

EMR systems are required to:<br />

i. Allow providers to enter orders with required details<br />

ii. Accept prescription orders<br />

iii. Order <strong>and</strong> adm<strong>in</strong>ister immunizations: capture dose, site given<br />

iv. Manage referral orders with details of referr<strong>in</strong>g provider <strong>and</strong> referred-to provider.<br />

Health In<strong>for</strong>mation <strong>and</strong> Report<strong>in</strong>g<br />

One advantage of EMR systems is to improve the report<strong>in</strong>g <strong>and</strong> use of health <strong>in</strong><strong>for</strong>mation. To<br />

support this function, EMR systems are required to:<br />

i. Generate reports from cl<strong>in</strong>ical data to support quality improvement<br />

ii. Generate aggregate reports <strong>for</strong> submission to health m<strong>in</strong>istries <strong>and</strong> other consumers.<br />

Support<strong>in</strong>g Security <strong>and</strong> Confidentiality<br />

Health data security <strong>and</strong> confidentiality is fundamental to any EMR system to ensure that the<br />

privacy of patient data is ma<strong>in</strong>ta<strong>in</strong>ed. EMR systems are required to:<br />

<strong>St<strong>and</strong>ards</strong> <strong>and</strong> <strong>Guidel<strong>in</strong>es</strong> <strong>for</strong> <strong>Electronic</strong> <strong>Medical</strong> <strong>Record</strong>s <strong>Systems</strong> <strong>in</strong> Kenya 19

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