Question

It is important for physicians to connect with behavioral health. Some medications cause mental health issues. Therefore, the health record should also tie more professionals together and adapt new models of care. Conduct research on the Comprehensive Medical Record (CMR) to foster connections between primary care physicians, multiple specialists, hospitals, clinics, pharmacies, laboratories, public health registries, and new models of care such as Accountable Care Organizations (ACOs). What are some of the most prevalent challenges with implementing the CMR to include behavioral healthcare?

Answer 1

A comprehensive medical record is a medium to record all the communication related to the patient's physical and mental health with the purpose of providing treatment and evaluate the current health status. The medical record should be comprehensive and we'll organized with up-to-date data to foster quality health service and effective treatment.

There are many medical records for a single patient depends on the domains of health service they reciebre. Each health personnel maintain that particular record. But a comprehensive medical record is the one which incorporates all the details from all the medical personnel. The various streams of health service such as physician, multi specialists, pharmacists , nurses, dietitian, laboratories etc are integrated in the comprehensive medical record.

The main components that should be included in the comprehensive medical record includes :

1. Behavioural health information from the behaviour health providers

2. Member identification details

3. Demographic data

4. Family history

5. Social history

6. Past medical history

7. Immunization records

8. Dental history if any

9. Current problem list

10. Current medications

11. Documentation regarding:

Laboratory test, screening , radiology report , physical examinations , reports from referral, consultation and specialist, emergency care report , hospital discharge summaries , behaviour health referrals and services provided , behavioural health history and behaviour health information

12. Documentation that considers all the diagnostic and therapeutic information related to the patient should be transmitted to all the providers for vontinuicoof care and quality service for managing the members.

Some of the existing challenges to implement the comprehensive medical record are as follows:

1. Interoperability- exchanging information from various domains. It's one of the main challenge to gather the information from each provider

2. Lack of commitment: The providers may exercise last of commitment which may trouble the maintenance of record by providing the accurate information.

3. Lack of confidentiality: As all the information including behavioural health information is included in the record and will be transmitted to all the providers lack of confidentiality may occur.

4. Difficulty in maintenance: Maintaining a longitudinal medical record of the same member cared by multiple parties or providers are very difficult .

Even if some challenges are existing, it has huge benefits to provide efficient and quality care with integrity and continuity.