What are Electronic Medical Records

The days of paper records are long gone in thousands of hospitals, clinics, and other health care facilities across America. These bulky records that were incredibly difficult to sift through and nearly impossible to keep track of over the years have been increasingly replaced by the EMR, which is an electronic medical record. By keeping important patient information in a digital format rather than in a paper format, the information is not only easier to access, but also more easily usable by all members of the health care team.

EMR

Numerous doctors working in health care offices across America use some type of EMR system today. The incredible popularity of the EMR proves just how well it is working for physicians across numerous specialties. Understanding more about the EMR, how it works, and who can best use it can prove just how essential it is for any health care organization these days.

The acronym EMR stands for electronic medical record, which is a digital version of the paper medical record that has been used for years.

The EMR replaces the older and bulkier record with a much more efficient and easily accessed chart that is conveniently stored online or in the cloud. An EMR contains a great deal of information about each patient, and this information can be accessed by all providers within the healthcare team. It will contain the patient’s medical and surgical history, allergy information, treatment history, current, and past prescriptions, and other pertinent information that can be used in making future medical decisions.

Why Use EMRs?

Although EMRs may initially seem like smart replacements for problematic paper records, they are actually much more than that. Because all the information about a patient is stored digitally, the entire ^healthcare team can see applicable information, which will then guide care. This allows for a more coordinated experience for everyone involved along with improved patient care.

In fact, the EMR will be gradually built up over the years as the patient progresses through the ^healthcare system. All providers within the system can add to the EMR, eventually creating a very comprehensive and highly accurate look at the patient’s health.

Clinic notes, hospital charting, and treatment records from ancillary health care personnel at the facility can guide the diagnosis and treatment of future medical events.

Because of the EMRs ability to store important patient data over time and to keep track of trends, patients are more easily monitored, and even smaller health changes are harder to miss. Plus, health care staff find it easier to track patients for preventative care and regular health screenings with the EMR, potentially improving the patient’s overall health and wellness as they age.

Who Uses EMRs?

EMRs are readily accessible to all types of clinicians. Not only do doctors in clinic offices use them, but physicians and specialists in the hospital setting can read them and chart in them as well to create the most comprehensive record possible. In addition, other types of clinicians can access the EMR, including physical therapists, pharmacists, nurses, and a variety of other ancillary health care staff within the system.

Just as importantly, the patient themselves may also be able to access their own EMR depending on the healthcare system’s policies. This open look at their own health care plan can help the patient become their own advocate and can keep them more invested in their overall health. The patient may be able to view after-visit summaries, laboratory results, radiology reports, and more so that they can be better informed about caring for themself.

Gaining Popularity

Although not every medical office across the United States uses EMRs today, their use is increasingly widespread throughout the country as many continue to realize the amazing benefits of the digital chart format. As technology has advanced, the ease of using the EMR has improved as well.

In fact, according to the U.S. Centers for Disease Control and Prevention, 85.9% of office-based physicians are using some type of EMR or EHR system today. This number has improved significantly in the past 10 to 15 years.

History of EMRs

Although the EMR has seemed to burst onto the scene more recently as it has become increasingly popular and mainstream, its roots actually go much further back. Electronic hospital information systems first began to be developed in the 1960s, and the EMR arrived a short time later.

• In 1972, an EMR was first developed at Regenstrief Institute, Indianapolis, Indiana.
  
• In the 1990s, EMRs were used with more frequency as more people had access to high-quality, affordable computers and as the Internet began making EMR storage easier.
  
• In 2009, the American Recovery and Reinvestment Act (ARRA) was passed, and it included billions of dollars to help health care organizations implement EMRs in their facilities.
  
• In 2009, as part of ARRA, the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed, which provided $27 billion in incentives for health care systems that chose to install and use EMRs.
  
• By 2014, this call for EMRs to be used across the healthcare industry had continued to be upheld. Approximately 10 years earlier, a sub-cabinet National Health Information Coordinator position was created under President George W. Bush.
  

Advantages

While the incentive program for adopting and implementing EMRs certainly stimulated the move to the electronic medical record for many practices, not all organizations have followed suit. The few who have not yet adopted EMRs not only find themselves faced with stiff penalties based on approved Medicare-covered amounts but also find that they cannot enjoy the amazing advantages of EMRs that their fellow practitioners are experiencing. While EMRs create many advantages for physicians, patients, and the health care system as a whole, the top six benefits are listed below.

1. Improved Quality of Care

EMRs can significantly improve the quality of care that a patient receives. On a National Patient Survey from 2014, 65% of physicians stated that using EMRs had improved the patient care that they were able to provide. Of course, EMRs have improved significantly since then, allowing healthcare providers to do even more with these digital charts than they could in 2014.

There are many ways that EMRs have helped improve the quality of health care as a whole. With the EMR, both the physician and the patient are better informed because they have all of the necessary information at their fingertips. Physicians can quickly find medications, values, and diagnoses with a few taps of a button. In addition, the EMR has improved relationships between primary care providers and other members of the healthcare team, including specialists and ancillary personnel, thanks to improved communication. In addition, the workflow is also simpler and charting is more efficient, helping clinicians save time and see more patients in the course of their day.

2. Space Saving

In years past, huge buildings were needed to house patient records for a health care system. When a physician needed to see past patient records, they would have to request the record from the storage facility, wait for it to arrive, and page through potentially hundreds of pages of information to find what they needed. As opposed to EMRs, which are stored digitally and do not require any physical space. They can be accessed immediately, and providers can sift through information quickly in one place as it is all organized.

3. Organizational Benefits

Besides the incredible size of growing patient charts over the years, these charts were also easy to misplace. If they were misfiled in the storage facility, it could take days or even months before they were uncovered again. This loss of patient information, no matter how brief, could lead to ineffective or even dangerous care.

Additional workers are no longer needed to file and sort paper charts. By removing this possibility for human error, patient charts are kept far safer than they once were. Plus, more than one health care worker can now access the same chart simultaneously, providing better continuity of care and a speedier diagnostic and treatment process.

4. Legible Chart Notes

While illegible writing by doctors has become a sort of joke around the nation, it is truly a problem that can lead to unintended and possibly life-changing consequences. If a prescription cannot be read clearly, the nurse may give more medication than the patient should have, or even given incorrect medication. Even slight differences in charted notes and treatment orders can make a huge difference in the quality of life for a patient. With the EMR, orders can be clearly typed out for anyone to read easily. In addition, today’s EMRs often use pre-typed order sets that physicians can checkmark to clearly notate what a patient needs, making it easier to ensure the proper medication and dose are given to the patient.

5. Reduced Need for Transcription Staff

In the past, health care organizations have had to hire numerous transcriptionists to listen to recorded notes before typing them out accurately. This process can take some time to complete and may not be done correctly if the transcriptionist cannot understand the clinician. EMR software not only eliminates this possibility for unintended errors but also decreases the cost of hiring additional personnel. The process can now be done automatically and immediately during or following a patient visit.

6. Improved Prescription Process

The EMR can also communicate directly with the majority of pharmacies these days, eliminating the need for paper prescriptions that can be easy to lose or misread and speeding up the process of getting an important medication to a patient. In addition, health care personnel no longer have to call prescriptions into pharmacies. The electronic transmission of a prescription can also increase the likelihood that a patient will fill and use prescribed medication.

Difference Between EHRs

The EMR is often confused with the EHR. Although they are similar in some respects, it should be noted that each type of digital record has different uses and limitations.

Electronic Medical Record Versus Electronic Health Record

Although there may only be one word that is different between the electronic medical record (EMR) and the electronic health record (EHR), there is actually a great deal of difference between the two in practice. As previously mentioned, the EMR is a digital chart that a health care practice or organization uses to maintain a patient record. It eliminates the older paper chart and can often communicate with a pharmacy, but it cannot be shared with other providers outside the practice. It is primarily used by physicians to aid in their diagnosis and treatment of a patient.

On the other hand, the EHR is a more comprehensive record that includes much more information that is usable for both the patient and any physicians they may see in the future. Because the EHR is shareable, this record can move along with a patient should they move or change health care practices. While it includes much of the same information that the EMR does, it will also include a wide variety of other information, such as messaging between the patient and providers, billing information, health care education, and much more.

The word difference between the names of these records clearly shows the key difference between these two types of charts.

While the EMR mainly includes medical data used for diagnosis and treatment, the EHR contains all pertinent health information that can be used by any provider and by the patient themself throughout the course of their life.

Conclusion

EMRs can be used by healthcare organizations and practices of any size and can provide significant benefits to providers and patients alike. By easing some of the administrative aspects of health care, the EMR helps providers save time, see more patients, provide better diagnostics, and prescribe the most targeted treatments.