With the recent passage of the Health Care Reform Bill, we are reviewing our nations’ health options looking for a way to make a positive impact. One of these ways is to bring medical documentation into the 21st century.
With the focus on this area, people have been using the terms, EMR (electronic medical records) and EHR (electronic health records) interchangeably. Electronic medical records and electronic health records are not the same thing. To better understand the issues involved and the incentives to transfer paper documents, to electronic media, let’s define what a medical record is.
A medical record is a legal document generated by a care provider (doctors, hospitals etc.) which records patient statistics and the care received from the provider. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and manipulation of records. Typically, they are the property of the provider.
To define an EHR (electronic health record), please see the quote below taken from the National Institute of Health NNCR’s Electronic Health Records’ Overview:
“The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface-including evidence-based decision support, quality management, and outcomes reporting.”
The question facing an aging nation is not whether medical documents should be digitized, but what is the best way to make it happen. The reasons for making the transition deal with more than just taking the doctor’s illegible writing out of the record loop. The amount of records generated during a patient’s tenure with a healthcare provider can be enormous. Typically, older records are archived and stored, sometimes at a location other than where care is provided. This makes access inconvenient and therefore unlikely.
Electronic health records would give providers access to critical information in emergency rooms across the country, especially when the patient is outside their normal geographic area. It also makes a more seamless medical care experience for patients who chose to change providers.
NIH argues for the value of EHRs in the quote below:
The first known medical record was developed by Hippocrates, in the fifth century B.C. He prescribed two goals:
* A medical record should accurately reflect the course of disease.
* A medical record should indicate the probable cause of disease.
These goals are still appropriate, but electronic health record systems can also provide additional functionality, such as interactive alerts to clinicians, interactive flow sheets, and tailored order sets, all of which cannot be done be done with paper-based systems.
The terms EMR and EHR have been used interchangeably, they should not be:
EMR as medical practice software
A local primary care physician or a doctors office would want to run it’s billing and scheduling off of a Medical practice software (often called an EMR), as it turns out it’s useful for that accounting software to also keep patient medical records.
A hospital or medical facility would want to access an all encompassing EHR database, that Electronic Health Record would be a network of local nodes or local EMR patient records.
An EHR could be considered a collection of EMR’s in a parent child relationship.
With every step forward in technology, there are the naysayers, the group that supports the status quo: the “if it ain’t broke, don’t fix it mentality.” With this mindset, people wouldn’t ever travel by air, much less land on the moon. While there is a place for prudence and conservatism, there is no place for letting fear of the unknown hold us hostages in the past.
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