Basics of EMR (Electronic Medical Records) Systems

Basics of EMR (Electronic Medical Records) Systems

Nomenclature

Most physicians today are probably familiar with the term EMR, for electronic medical records. Some insurance companies and government agencies are now using the term EHR, for electronic health record. What is the difference? EMR is commonly used to describe an electronic version of a paper medical chart whereas an EHR can also include any relevant data associated with that individual person: previous insurance coding information, hospital visits or procedures, etc. Many people use these terms interchangeably.

EMR vs. EMR System

As mentioned above, an electronic medical record is a digitized version of a patient's paper record. This can merely be a scanned copy of the office chart, which can then be accessed via an office network with third party software (scanning solution).

An EMR system is specialized software which is usually specific to a particular medical specialty and requires data input by the user. The patient data is typically entered through templates, which can be customized depending on the software system, and stored in a database, either on an on-site server or off-site via an application service provider (ASP) model.

The advantage of the scanning solution is a lower cost, faster learning curve, and ease of implementation. The disadvantage is that the data is read-only and cannot be directly accessed or manipulated for any other use such as trends or studies.

The primary advantage of the EMR system is a more robust solution which allows direct data access and analysis for such things as pay-for performance, a government reimbursement program facing physicians in the near future, and clinical trends for better patient care and for research purposes. The disadvantages include a higher cost in most cases, steeper learning curve for end-users, and more formidable implementation requirements, such as infrastructure and hardware.

Methods of Data Entry

Most EMR systems allow for different forms of data entry by the end-user. The simplest is data entry via a keyboard - this is used in more basic, text-only systems. Some systems are now available with touch-screen graphic interfaces and templates, with pick-lists and drop-down menus requiring little or no typing of text. Other systems offer voice data-entry and/or control, usually via third-party voice dictation software.

Touch-screen data entry will require more complex hardware such as pen tablet or slate PCs. A more economical option would be tablet thin client devices, which are lighter and more comfortable to carry from room to room. Bear in mind, however, that all of these devices are portable and require an adequate wireless environment. The true range of most wireless access points within the typical medical office building often does not achieve the advertised range.