Term: Electornic Medical Record - EMR

Description: An EMR sometimes reffered to as an EHR is an Electronic Medical Record. They are used to help keep track of a patients medical history and are updated by physicians. The overall goal of an EMR is to eventually rid most practices of using the older paper medical records. This requires that older paper records bust be either transcribed or scanned to create individual EMRs that would eventually make up an EHR this requires an enormous amount of time and money on the physicians part, and is viewed is inpratical by smaller firms. Recently the federal government decided to try and standardize EMR's across the board and and have enlisted the help of CCHIT or the Certification Commission for Healthcare Information Technology. The CCHIT was given the task to create criteria for a standard that all EMRs most follow. Currently most physicians still use the older more conventional way of keeping records and as of 2005 only 12 percent of practices where using them. According to George Bush by the year 2014 all physians should have fully functional EMR systems.

There are many functions associated with patient health records. Not only is the record used to document patient care, but the record is also used for financial and legal information, and research and quality improvement purposes. Because all this information must be shared among many professionals who constitute the healthcare team and there continue to be problems with the paper health record, it is becoming more apparent that developing an automated health record is very important. The EMR provides the opportunity for healthcare organizations to improve quality of care and patient safety. An EMR also represents a huge potential for cost savings and decreasing workplace inefficiencies.

An EMR facilitates:
1. Easy look up of patient data by clinical staff at any given location
2. Accurate and complete claims processing by insurance companies
3. Building automated checks for drug and allergy interactions
4. Clinical notes
5. Prescriptions
6. Scheduling
7. Sending and viewing labs

What is the difference between an EHR and an EMR?

Not much, if any. The world of medical practice software is constantly seeking new ways to describe the various options out there for doctors. However, not many can keep all of it straight, so everyone just uses what they feel to be the most popular acronym. At EMRWorld, we tend to use EMR, electronic medical records, or sometimes EHR, electronic health records.


Legal status

Medical records, such as physician orders, exam and test reports are legal documents, which must be kept in unaltered form and authenticated by the creator.

Percentage Of Office-Based Physicians Using Electronic Medical Records, By Specialty


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Current EMRs certified by CCHIT in 2007:
company (product version)
date certified
Community Computer Service
(MEDENT 17)
7/11/2007
eCast Corporation
(eCast EMR 7.0)
9/21/2007
eClinicalWorks, LCC
(eClinicalWorks 7.6.15)
8/10/2007
e-MDs, Inc.
(e-MDs Solution Series 6.1.2)
7/18/2007
Greenway Medical Technologies
(PrimeSuite 2007 R2)
6/22/2007
McKesson Provider Technologies
(Practice Partner 9.2.1)
7/17/2007
NextGen Healthcare Information Systems, Inc.
(NextGen EMR 5.4.29)
6/25/2007
Purkinje
(CareSeries EHR 2.0)
7/27/2007
For a complete list visit http://www.cchit.org/choose/ambulatory/2006/index.asp

Advantages of EMR's

  • There are increasing storage capabilities for longer periods of time.
  • Also, the EMR is accessible from remote sites to many people at the same time and retrieval of the information is almost immediate. The record is continuously updated and is available concurrently for use everywhere. Information is immediately accessible at any unit workstation whenever it is needed.
  • The EMR can also provide medical alerts and reminders. EMR systems have some built-in intelligence capabilities, such as recognizing abnormal lab results, or potential life-threatening drug interactions. Research findings supporting diagnostic tests and the EMR can link the clinician to protocols, care plans, critical paths, literature databases, pharmaceutical information and other databases of health care knowledge.
  • Computer systems should not take the place of physicians’ critical judgments however, a well-designed EMR supports accountable autonomy, collecting and disseminating information to assist the medical professional in decision making. Today, reimbursement is based on outcomes therefore healthcare organizations must seek innovative ways to improve quality of care and outcomes while managing costs. An EMR can decrease charting time and charting errors, therefore increasing the productivity of health care workers and decreasing medical errors due to illegible notes. “Reduction of medical errors is the concern of the public at large, state legislators, health care providers, and many other health professionals.
  • Since handwriting is instinctive, and therefore difficult to change automated systems can help eliminate this problem. Although some systems may seem costly, the gains in efficiency far offset the costs. Chart chasing is eliminated, as is duplicate data entry of the same information on multiple forms. Highly paid, skilled clinicians no longer are delayed by the search for elusive paper charts, and usable outcome information becomes available without several days of data compilation. The EMR will provide more accurate billing information and will allow the providers of care to submit their claims electronically, therefore receiving payment quicker. The patient is even happier, because previous information is available so the patient does not have to continue to provide the same information over and over again.

Disadvantages of EMR's

  • Some of the disadvantages include such items as the startup costs, which can be excessive. At a time when healthcare organizations need to reduce their costs, allocating capital to information systems is still a challenge. However, some believe that an EMR can not only reduce costs but also improve quality of care through better-informed healthcare providers and patients, the elimination of duplicate testing, and better coordination of treatment by more than one healthcare provider.
  • Another disadvantage to an EMR is that there is a substantial learning curve and it is helpful if the users have some type of technical knowledge. Today, clinicians are the primary users of EMRs as opposed to the main users of the past, which where clerks. One of the more challenging issues confronting EMRs is the fact that physicians must be the users of the system, performing data entry (e.g., orders, progress notes) as well as information retrieval, if they are to realize the benefits of interactive on-line decision support. Confidentiality and security issues are concerns associated with both the paper health record and the EMR.
  • Patient record must be protected, the patient must also remember that the record has to be accessible to the professionals who use the records to provide medical care. Laws must not be so stringent as to prohibit access to those with a legitimate right to information.
  • Placement of hardware is an issue and decisions regarding the portability of the equipment must also be considered. Since workflow will change after the implementation of an EHR, decisions must be made to determine who enters the data and documentation forms must be revised in order to accommodate the changes.

E-Prescribing through EMR's

Ensuring that patients receive the correct medication has never been easier or more convenient. NextGen EMR provides an ePrescribing module that allows physicians to order, record, and transmit a prescription directly to the pharmacist, ensuring that no information about dosage, frequency, etc., becomes lost in translation or transport. Partnering with Surecripts, RxHub, and MediMedia, providers, through NextGen EMR, can search medication lists, automatically check for drug-to-drug interactions and drug allergies, and perform a real-time formulary confirmation in MediMedia’s InfoScan Formulary Database. They can then instantly transmit the prescription to the patient’s local participating pharmacy through the SureScripts network, or, if desired, approve direct mailing of the medications to the patient through the RxHub program.
With this direct connectivity, pharmacists also are able to respond directly with questions or requests for additional information or refills. As a result, fewer errors are made and patient safety is protected.
Applications:

Web Resources:
http://www.nuesoftxpress.com/products/electronic_medical_record/electronic_medical_record.html
http://www.medinformatix.com/
http://www.cchit.org/


Related Terminology:

EHR
RHIO
HIT

Citations/References
http://en.wikipedia.org/wiki/Electronic_medical_record
http://www.cchit.org/choose/ambulatory/2007/index.asp
http://www.emrworld.net/emr-research/ehr.php
http://en.wikipedia.org/wiki/Electronic_medical_record#Social_and_organizational_barriers
http://www.aameda.org/memberservices/Exec/Articles
http://www.whitehouse.gov/omb/egov/press/CHI_April.htm


Eprescribing
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