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Electronic medical record

An electronic medical record (EMR) is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office.[1] Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records.


Comparison with paper-based records

Paper-based records are still by far the most common method of recording patient information for most hospitals and practices in the U.S.[2] The majority of doctors still find their ease of data entry and low cost hard to part with. However, as easy as they are for the doctor to record medical data at the point of care, they require a significant amount of storage space compared to digital records. In the US, most states require physical records be held for a minimum of seven years. The costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media. When paper records are stored in different locations, collating them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. This is particularly true in the case of person-centered records, which are impractical to maintain if not electronic (thus difficult to centralise or federate). When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records. Because of these many "after entry" benefits, federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic medical records. Congress included a formula of both incentives (up to $44K per physician under Medicare or up to $65K over 6 years, under Medicaid) and penalties (i.e. decreased Medicare/Medicaid reimbursements for covered patients to doctors who fail to use EMR's by 2015) for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.[3]

One study estimates electronic medical records improve overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of only a few "unnecessary" tests or admissions.[4][5] Jerome Groopman disputed these results, publicly asking "how such dramatic claims of cost-saving and quality improvement could be true".[6]

However, the increased portability and accessibility of electronic medical records may also increase the ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users versus paper medical records as acknowledged by the increased security requirements for electronic medical records included in the Health Information and Accessibility Act and by recent large-scale breaches in confidential records reported by EMR users.[7][8] Concerns about security contribute to the resistance shown to their widespread adoption.

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.[9] Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.[10][11]

In contrast, EMRs can be continuously updated (within certain legal limitations see below). The ability to exchange records between different EMR systems ("interoperability"[12]) would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.[13]

Contribution under UN administration and accredited organisations

The United Nations World Health Organization (WHO) administration intentionally does not contribute to an internationally standardized view of medical records nor to personal health records. However, WHO contributes to minimum requirements definition for developing countries.[14]

The United Nations accredited standardisation body International Organization for Standardization (ISO) however has settled thorough word for standards in the scope of the HL7 platform for health care informatics. Respective standards are available with ISO/HL7 10781:2009 Electronic Health Record-System Functional Model, Release 1.1[15] and subsequent set of detailing standards.[16]

EMRs in the United States


Even though EMR systems with a computerized provider order entry (CPOE) have existed for more than 30 years, fewer than 10 percent of hospitals as of 2006 had a fully integrated system.[17]

In the United States, the CDC reported that the EMR adoption rate had steadily risen to 48.3 percent at the end of 2009. [18] This is an increase over 2008, when only 38.4% of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2008.[19] However, the same study found that only 20.4% of all physicians reported using a system described as minimally functional and including the following features: orders for prescriptions, orders for tests, viewing laboratory or imaging results, and clinical notes.

The cost of implementing an EMR system for smaller practices has also been criticized. Despite this, tighter regulations regarding meaningful use criteria have resulted in more physicians adopting EMR systems. Software, hardware, and other services for EMR system implementation are provided for cost by various companies, including Dell.[20] Additionally, there is a wide range of open-source EMR system software.

Legal status

Electronic medical records, like medical records, must be kept in unaltered form and authenticated by the creator.[21] Under data protection legislation, responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law.[22]

Technical features

Using an EMR to read and write a patient's record is not only possible through a workstation but depending on the type of system and health care settings may also be possible through mobile devices that are handwriting capable.[23] Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from an EMR readily visible and accessible for consumers.

Event monitoring

Some EMR systems automatically monitor clinical events, by analyzing patient data from an electronic health record to predict, detect and potentially prevent adverse events. This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes.[24]

Role in an electronic research network

The Electronic Primary Care Research Network connects medical practitioners to researchers; promoting practice based research networks and facilitating clinical research. The internet-based infrastructure provides researchers with electronic medical records and standardized clinical report forms, shifting dependence away from paper based data collection tools that are not standardized. This mode of communication improves the quality of primary care and increases the number of clinical research opportunities. The information exchange between health care organizations encourages the translation of research into primary care practices.

EMRs in Europe

There is no common standard on EMRs in Europe neither in the entire member states of the European Union. Exception is with those states where health care system is unified, as in United Kingdom.

EMRs in ambulances

Ambulance Services in Australia have recently introduced the use of EMR systems [25] The benefits of EMR in Ambulance include the following: better training for paramedics, review of clinical standards, better research options for pre-hospital care and design of future treatment options [26]

Automated handwriting recognition of ambulance medical forms have also been successful. These systems allow paper based medical documents to be converted to digital text with substantially less cost overhead. Patient identifying information would not be converted to comply with government privacy regulations. The data can then be efficiently used for epidemiological analysis. [27]

GP2GP project

GP2GP is an NHS Connecting for Health project in the United Kingdom. It enables GPs to transfer a patient's electronic medical record to another practice when the patient moves onto the listctice.[28]

Privacy concerns

A major concern is adequate confidentiality of the individual records being managed electronically. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and over 600,000 payers, providers and other entities that handle providers' billing data have some access.[29]

In the United States, this class of information is referred to as Protected Health Information (PHI) and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws.[30]

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[31]

Technical standards

Though there are few standards for modern day EMR systems as a whole, there are many standards relating to specific aspects of EMRs. These include:

  • HL7 messages format for interchange between different record systems and practice management systems.
  • ANSI X12 (EDI) A set of transaction protocols used in the US for transmitting virtually any aspect of patient data.
  • CEN CONTSYS (EN 13940), a system of concepts to support continuity of care.
  • CEN EHRcom (EN 13606), a 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 standard for representing and communicating radiology images and reporting

Interoperability towards sharing records

In the United States, the development of standards for EMR interoperability is at the forefront of the national health care agenda.[32] EMRs, while an important factor in interoperability, are not a critical first step to sharing data between practicing physicians, pharmacies and hospitals. Many physicians currently have computerized practice management systems that can be used in conjunction with a health information exchange (HIE), allowing for first steps in sharing patient information (lab results, public health reporting) which are necessary for timely, patient-centered and portable care.

The future vision of many connected health systems is the ability to connect the electronic medical record system to a personal health record creating a "shared record". This sharing will have to include elements of granular permissions at the data type level and the ability for patient generated content to be "tagged" allowing the provider to maintain clinical integrity of information. An example of this can be seen in implementations of connected health platforms that have this capability built in like HealthyCircles. [33]

Regulatory compliance

  • Health Insurance Portability and Accountability Act
  • Health Level 7
  • Title 21 CFR Part 11

In veterinary medicine

In UK veterinary practice, the replacement of paper recording systems with electronic methods of storing animal patient information escalated from the 1980s and the majority of clinics now use electronic medical records. In a sample of 129 veterinary practices, 89% used a Practice Management System (PMS) for data recording.[34] There are more than 10 PMS providers currently in the UK. Collecting data directly from PMSs for epidemiological analysis abolishes the need for veterinarians to manually submit individual reports per animal visit and therefore increases the reporting rate.[35]

Veterinary electronic medical record data are being used to investigate antimicrobial efficacy; risk factors for canine cancer; and inherited diseases in dogs and cats, in the small animal disease surveillance project 'VetCOMPASS' (Veterinary Companion Animal Surveillance System) at the Royal Veterinary College, London, in collaboration with the University of Sydney and RxWorks (the VetCOMPASS project was formerly known as VEctAR). [36]

See also

  • List of open-source healthcare software
  • Medical billing (United States)


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