An electronic medical record (commonly abbreviated EMR) is a generic term used to describe computer-based patientmedical records. The term has become expanded to include systems which keep track of other relevant medical information. The Practice Management System (commonly abbreviated PM) is a term used to describe the medical office functions which support and surround the electronic medical record.
An EMR facilitates
easy look up of patient data by clinical staff at any given location
accurate and complete claims processing by insurance companies
building automated checks for drug and allergy interactions
Although an EMR system has the potential to permit invasion of medical privacy, if security policies are monitored effectively EMRs are as secure as banking records, for example.
Electronic records fall under the purview of medical informatics, a combination of computation and computer science and medical record keeping. See Medical informatics for some historical remarks.
Related Terms
According to the Medical Records Institute (http://www.medrecinst.com/) 5 levels of an Electronic HealthCare Record (EHCR) can be distinguished:
The Automated Medical Record is a paper-based record with some computer-generated documents.
The Computerized Medical Record (CMR) makes the documents of level 1 electronically available.
The Electronic Medical Record (EMR) restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems.
The Electronic Patient Record (EPR) is a patient-centered record with information from multiple institutions.
The Electronic Health Record (EHR) adds general health-related information to the EPR that is not necessarily related to a disease.
Standards
Though there are few standards in modern day EMR systems, there are a number of standards and practices bodies which have drafted interchange formats which are in use.
HL7 - This format has been in use for interchange between hospital and physician record systems.
ANSI X12 (EDI) - Used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information.
Electronicrecords in health fall under the purview of health informatics, a combination of computation and computer science and medical record keeping.
These records are best described as "digital format records", as their content is not able to be modified or altered (with the exception of the use of a third party software to make "overlay notations") as electronicrecords are.
Further, all electronic repositories of information are subject to the need for periodic conversion and migration to ensure the formats they were captured in remain accessible over the life of the patient, and in some cases beyond, to the expected life of their heirs.
The main purpose of a medical record is “to serve as a basis for planning patient care and for continuity in the evaluation of the patient's condition and treatment.” (Van03).
The advantages of the electronicpatientrecord are meant to offset the disadvantages of the pen-paper system that has been in place for so long.
Ultimately, in the example given in an EPR awareness module (CHI03), the total time it took from the first visit to the family doctor to the end of operation and post-op took more than half the time in the “e-clinical case” than the fifty-four days it took in the traditional clinical case.
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