Electronic medical record

This redirect is about local computerised records in a specific health-care organization. For shared or comprehensive computerised health-care records in enterprise-wide systems, see Electronic health record.

An electronic medical record is usually a computerized legal medical record created in an organization that delivers care, such as a hospital and doctor's surgery. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and manipulation of records.

Contrast with paper-based record

Paper-based records require a significant amount of storage space compared to digital records. In the US, most states require physical records be held for a minimum of seven years. The costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media. When paper records are stored in different locations, collating them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. This is particularly true in the case of person-centred records, which are impractical to maintain if not electronic (thus difficult to centralise or federate). When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records..

One study estimates electronic medical records improve efficiency by 6% per year, and the monthly cost of an EMR is offset by the cost of only a few unnecessary tests or admissions. Jerome Groopman disputed these results, publicly asking "how such dramatic claims of cost-saving and quality improvement could be true".

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors. Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.

In contrast, EMRs can be continuously updated. The ability to exchange records between different EMR systems ("interoperability") would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.

Electronic Medical Records in the United States

Usage

Even though EMR systems with computerized provider order entry (CPOE) have existed for more than 30 years, fewer than 10 percent of hospitals as of 2006 have a fully integrated system.

In the United States, 38.4% of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2008. However, the same study found that only 20.4% of all physicians reported using a system described as minimally functional and including the following features: orders for prescriptions, orders for tests, viewing laboratory or imaging results, and clinical notes.

Legal status

Electronic medical records, like medical records, must be kept in unaltered form and authenticated by the creator. Under data protection legislation, responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law.

Electronic signature

Most national and international standards accept electronic signatures. According to the American Bar Association, "A signature authenticates a writing by identifying the signer with the signed document. When the signer makes a mark in a distinctive manner, the writing becomes attributable to the signer."

Technical Features

Using an EMR to read and write a patient's record is not only possible through a workstation but depending on the type of system and health care settings may also be possible through mobile devices that are handwriting capable. Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from a EMR readily visible and accessible for consumers.

Event monitoring

Some EMR systems automatically monitor clinical events, by analyzing patient data from an Electronic Health Record to predict, detect and potentially prevent adverse events. This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes.

GP2GP

GP2GP is an NHS Connecting for Health project in the United Kingdom. It enables GP to transfer a patient's electronic medical record to another practice when the patient moves onto the list of other practice

Privacy concerns

A major concern is adequate confidentiality of the individual records being managed electronically. According to the LA Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and over 9000 payers, providers and other entities that handle providers' billing data have some access.

In the United States, this class of information is referred to as Protected Health Information (PHI) and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws.

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.

Technical Standards

Though there are few standards for modern day EMR systems as a whole, there are many standards relating to specific aspects of EMRs. These include:

• XML - a document format allowing easy interoperability.
• HL7 - messages format for interchange between different record systems and practice management systems.
• ANSI X12 (EDI) - A set of transaction protocols used in the US for transmitting virtually any aspect of patient data.
• CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
• CEN - EHRcom (EN 13606), a standard for the communication of information from EHR systems.
• CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
• DICOM - a standard for representing and communicating radiology images and reporting

Interoperability towards sharing records

For more information on sharing records in health care, see Electronic health record.

In the United States, the development of standards for EMR interoperability is at the forefront of the national health care agenda.[2] EMRs, while an important factor in interoperability, are not a critical first step to sharing data between practicing physicians, pharmacies and hospitals. Many physicians currently have computerized practice management systems that can be used in conjunction with health information exchange (HIE), allowing for first steps in sharing patient information (lab results, public health reporting) which are necessary for timely, patient-centered and portable care.

Regulatory compliance

• HIPAA
• Health Level 7
• DICOM
• Title 21 CFR Part 11

See also

• List of open source healthcare software
• List of commercial healthcare software
  • SAS (software)
• Microchip implant (human)
• Medical billing (United States)

External Links

• EMR Mythbusters Podcast?