ELECTRONIC MEDICAL RECORD

1) DEFINITION:

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.

An electronic health record (EHR) (also electronic patient record

or computerized patient record) is an evolving concept defined as a
systematic collection of electronic health information about individual
patients or populations. It is a record in digital format that is capable of
being shared across different health care settings, by being embedded in
network-connected enterprise-wide information systems. Such records may
include a whole range of data in comprehensive or summary form, including
demographics, medical history, medication and allergies, immunization
status, laboratory test results, radiology images, and billing information.

EMR – “the practice management system that stores the health information
about the patient.”

EHR – “a data set of health information that can be packaged and routed to
another location, such as a lab, pharmacy, or another provider, to be opened
and read.”

PHR – “contains medical information and it is owned by the patient.”

OTHER NAME:
• CMR – Computerized Medical Record
• CPR – Computer-based Medical Record
• CCR – Continuity of Care Record
• EHR – Electronic Health Record
• EMR – Electronic Medical Record
• EPR – Electronic Patient Record
• PHR – Personal Health Record
• PMRI – Pt. Medical Record Information

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2) DIFFERENCE BETWEEN EMR & EHR:

Electronic Medical Records Electronic Health Records

1. The legal record of the CDO 1. Subset (i.e. CCR(Continuity

2. A record of clinical services for Of Care Record) or
patient encounters in a CDO CCD(Continuity Of Care
Document)) of information
3. Owned by the CDO (Care from various CDOs where
Delivery Organization) patient has had encounters

4. These systems are being sold
by enterprise vendors and
installed by hospitals, health
systems, clinics, etc
5. May have patient access to
some results info through a
portal but is not interactive
6. Does not contain other CDO
encounter information
2. Owned by patient or
stakeholder
3. Community, state, or regional
emergence today (RHIOs) - or
nationwide in the future
4. Provides interactive patient
access as well as the ability for
the patient to append
Information.
5. Connected by NHIN (National
Health Information Network)

3) COMPONENTS OF AN EHR:

• Clinical Documentation (e.g., progress notes)

2. Direct-entry
3. Voice recognition
4. Structured notes
• Summary Lists
1. Allergies
2. Medications
3. Problem
• Dictation/Transcription

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4) 10 BENEFITS OF AN ELECTRONIC MEDICAL
RECORD:

1. Speed:
In medical practices, speed equals ability to compete, especially when
managing information. That is why an electronic medical record system, or
EMR, is used by most medical practices

2. Storage

An electronic medical record is an electronic database of information

capable of carrying much more information than traditional systems.

3. Security

An electronic medical record system secures records with backup files in

case of emergencies. In addition, only authorized users may access them.
This double security system is a "preventative medicine" for record viruses.

4. Support

Both practices and patients can access customer support from a medical
billing specialist provided through the electronic medical record software.

5. Accessibility

The latest electronic medical record technology allows information to be

downloaded directly onto a PDA or Palm device.

6. Affordability

This is perhaps the most appealing part of the latest electronic medical
record technology. Every business wants to save money while at the same
time adopting time-saving technology.

7. Infrastructure

The infrastructure is simplified into one online database, even for multiple
offices.

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8. Versatility

Electronic medical record software stores medical transcription SOAP notes

and medical codes. It allows multiple users. It also connects users to
personal and online support sources.

9. Efficiency

Efficiency takes all of the duties involved in medical record and medical
office management divided by time and money.

10. Manageability

5) EMR EDUCATIONAL OBJECTIVES:

 Access patient information
 Documentation of Progress
 Chronic Disease Management
 Coding
 Communication
 Decision Support
 Patient Education Handouts
 Prevention/Health Maintenance
 Security and Privacy

6) DISADVANTAGES OF EMR:
 Start-Up Costs
 Difficulties in Implementation
1. Physician, Staff Resistance
2. Recent study: 11 of 14 groups were integrated an average of 26
months after implementation
3. Physician “Champions” of the project will have to invest dozens of
hours to facilitate implementation

 Initial Impact of Office Workflow

1. Doctors will work longer hours for an average of 4 months after
implementation

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 2. Can be mitigated by implementing record gradually (i.e. just
telephone calls, surgical follow-ups at first)

7) THE FUTURE
1. Widespread use of EMR and data storage in Regional Health
Information Organizations (RHIO’S) is a goal of many health policy
makers
2. It is debatable whether EMR will be a panacea for “the System’s” ills
3. All stakeholders want to “increase quality” yet Medicare and HMO’s
really are interested only in cutting costs.
4. EMR may save money at provider expense (decreased utilization)
5. EMR may also increase expense through increased payments because
of better coding!
6. Even considering above, there is no current effort to mandate EMR
use or pay for it
7. EMR may be able to facilitate proof of orthopedic value through
electronic outcomes data
8. When value is demonstrated, downward spiral of falling
reimbursement will end because differentiation will be made on
quality, not just price
9. Surgeons who provide quality care will be in great demand