Electronic medical record

An electronic medical record (commonly abbreviated EMR) is a generic term used to describe computer-based patient medical records. The term has become expanded to include systems which keep track of other relevant medical information. The Practice Management System (commonly abbreviated PMS) is a term used to describe the medical office functions which support and surround the electronic medical record.

An EMR facilitates

• easy look up of patient data by clinical staff at any given location
• accurate and complete claims processing by insurance companies
• building automated checks for drug and allergy interactions
• clinical notes
• prescriptions
• scheduling
• sending and viewing labs

As of 2005 one of the largest projects for a countrywide EMR is the NHS project in the United Kingdom. The goal of NHS is to have 60,000,000 patients with a centralized electronic medical record by 2010.

Although an EMR system has the potential to permit invasion of medical privacy, if security policies are monitored effectively EMRs are as secure as banking records, for example.

Electronic records fall under the purview of medical informatics, a combination of computation and computer science and medical record keeping. See Medical informatics for some historical remarks. See QIOs for information on federal initiatives in this area.

Related Terms

According to the Medical Records Institute 5 levels of an Electronic HealthCare Record (EHCR) can be distinguished:

• The Automated Medical Record is a paper-based record with some computer-generated documents.
• The Computerized Medical Record (CMR) makes the documents of level 1 electronically available.
• The Electronic Medical Record (EMR) restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems.
• The Electronic Patient Record (EPR) is a patient-centered record with information from multiple institutions.
• The Electronic Health Record (EHR) adds general health-related information to the EPR that is not necessarily related to a disease.

Standards

Though there are few standards in modern day EMR systems, there are a number of standards and practices bodies which have drafted interchange formats which are in use.

• HL7 - This format has been in use for interchange between hospital and physician record systems.
• ANSI X12 (EDI) - Used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information.

External links

• Journal of the American Medical Informatics Association
• The International Medical Informatics Association
• National Programme for IT in the NHS
• Doctors' Office Quality Information Technology (DOQ-IT)

Commercial EMR Systems:

• Companion EMR
• MedcomSoft
• Misys EMR
• NextGen EMR
• Practice Partner
• Intergy by WebMD
• Purkinje EMR

Free or open source EMR Systems:

• FreeMED - Wikipedia Article
• OpenEMR
• OSCAR
• ClearHealthClearHealth Documentation

EMR Discussion Forums

• Docs Board
• EMR Update