Electronic medical record

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An electronic medical record or EMR is a digital form of medical (hospital or clinic) record [1]. In common use, the term applies both to the record itself, and the applications that access it and interact with health care personnel.

Differences with EHR

While the Electronic health record or EHR is supposed to deal with the complete records of a person, in health and disease, the EMR is restricted to only disease conditions, as recorded in a hospital or a clinic.

An Electronic Patient Record is an EHR under the direct control of the patient.

Features and Uses

These are quite similar to those for the EHR.

Barriers

Dictated notes may be associated with inferior quality of care.[2]

Standards

Despite the absence of a single acceptable standard for EMR systems as a whole, there are many standards relating to specific aspects of EHRs and EMRs. These include:

  • ASTM International Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or EMR systems, allowing easy interoperability between otherwise disparate entities.[3]
  • ANSI X12 (EDI) - A set of transaction protocols used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare.
  • CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
  • CEN - EHRcom (EN 13606), the European 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 heavily used standard for representing and communicating radiology images and reporting
  • HL7 - HL7 messages are used for interchange between hospital and physician record systems and between EMR systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other material.
  • ISO - ISO TC 215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
  • openEHR - next generation public specifications and implementations for EHR systems and communication, based on a complete separation of software and clinical models.

Various factors involving the timing, the right players, market history, utility, governance play a key role in the overall enrichment of the standard and certification development. The standardization and certification even though seem to bring uniformity in the EMR development, do not guarantee their acceptability and sustainability in the long run. [4] In 2005 the US Federal Government awarded a contract to CCHIT - Certification Commission for Healthcare Information Technology to develop certification criteria for EMR. Starting in early 2007 vendors began to utilize these certification criteria for their EMR system.

Implementation vis-a-vis customization and work flow assimilation

References

  1. Managed Healthcare Terms - E Words. Retrieved on 2008-01-28.
  2. Linder JA, Schnipper JL, Middleton B (2012). "Method of electronic health record documentation and quality of primary care.". J Am Med Inform Assoc. DOI:10.1136/amiajnl-2011-000788. PMID 22610494. Research Blogging.
  3. Nainil C. Chheda, MS (November 2005). "Electronic Medical Records and Continuity of Care Records - The Utility Theory". Application of Information Technology and Economics. Retrieved on 2008-01-29.
  4. Nainil C. Chheda, MS (January 2007). "Standardization & Certification: The truth just sounds different" (PDF). Application of Healthcare Governance. Retrieved on 2008-01-29.