1.1 What is an Electronic Medical Record (EMR)?
Electronic Medical Record (EMR), also known as Electronic Health Record (EHR) or Computerized Patient Record (CPR) is a patients’ medical record in an electronic format, accessible by computers on a network for the primary purpose of providing health care and health-related services. Information in an EHR includes documents relating to the past, present and/or future physical and mental health and condition of a patient, medical test reports or multimedia images, and financial and demographic information. In addition, ordering of medical tests, treatments, medications, and clinical guidelines used for the patient's care, are accessible within the EHR during the encounter. EHR data can be captured or transmitted, received or updated, stored or retrieved, securely and in real-time by users at the point of care or distant locations.1
The term Electronic Medical Records or EMR is often used loosely and in a number of ways, however a true EMR must perform the following functions:
EMR systems capture patient data
True EMR systems are designed to capture data at the point of care using a database, rules engine and knowledge bases as the primary source of information. The information is then submitted into the system via a computer workstation, notebook computer, tablet pc, pocket pc or voice recognition system.
EMR software integrates with other data sources
An EMR must be capable of integrating with multiple systems including administrative, financial and clinical departmental systems. The concept behind this is to save time by reducing double data entry in the other systems but also to ensure the quality of data throughout the entire system. Examples of this would include integration with hospital, billing, practice management, laboratory, imaging and pharmacy systems. This integration is made possible thanks to HL7 (Health Level 7) interfaces. An HL7 interface is a common language for sending and receiving messages from other systems, most commonly between practice management and EMR systems and between hospitals and physician offices.
EMR assists in provider decision making
By capturing data at the point of care, systems can aid in caregiver decision-making by accessing a rules engine to provide alerts, reminders, clinical protocols, coding assistance (ie. E/M level coding). With the integration of Lab, Pharmacy, Imaging and other EMR systems, EMRs can provide real-time data to the provider, thereby facilitating better clinical decision-making. With EMR comes access to large amounts of data at the click of a mouse permitting providers to analyze and report data quickly and easily, including clinical statistics analysis, population health, patient/drug reports, and patient demographic reports.
NEXT: EMR Functions
