Electronic Medical Record - Success Or Failure In The Medical Decision From The Romanian Health System ?

The investments in informational and communicational technologies in the health field represent a for of investing in human capital because health and medical services will exceed the physician – patient relationship and the improvement of the physical and emotional condition of the individuals of a society will become a prioritary problem of the community. In Romania is noticed a high degree of data fragmenting, with a negligible communication, often inexistent, within and outside the system, and the decision makers of the health system hold exclusivity on their own data, fact that makes them unavailable to the other participants to the system. The software-s, the formats and supports used differ both inside the system and outside it. And because a patient is given a diagnosis without complete and safe medical data, the medical error is one of the causes for the incorrect diagnosis of the patient. The decision makers from the health system must take on responsibilities for the efficient and safe management of these data, to represent a desired issue for all medical institutions. Only the interconnected and standardized electronic medical files will be able to improve the medical decision and the care given to patients. The care will be safer, more efficient, the medical information will be also useful to other clinic physicians in time and space by using the informational and communicational technologies. The complete electronic medical record must include all types of information connected to the patient`s health (medical, family history, health file, hereditary-collateral antecedents, treatments, prescriptions, allergies) and they must be protected, shared by physicians, patients and those interested in a safe and extended environment. It is necessary to computerize the medical information specific to patient and the clinical processes, and performance in the health system will depend on the transformation of the medical services system by bringing the benefits of the medical science and technology to all individuals.