What is an electronic medical record (EMR)? An electronic medical record (EMR) is a digital version of all the information in a provider’s paper chart, including medical history, diagnoses, medications, immunization dates, allergies, lab results, and doctor’s notes.
EMRs are online medical records that contain standard medical and clinical data from a single provider’s office and are mainly used for diagnosis and treatment by providers.
In EMRs, complete and accurate documentation of a patient’s medical history, tests, diagnosis, and treatment ensures appropriate care is provided throughout the provider’s clinic.
EMRs are more than just paper record replacements. They enable effective communication and coordination among healthcare team members to provide patients with the best care.
Its natural evolution began in the 1960s when we started to see “problem-oriented” medical records (as we know them today) rather than just the diagnosis and treatment provided by a doctor. Third-party facilities were able to independently verify the diagnosis for the first time.
Many of the first computer applications were used in hospitals at the dawn of the computer era, but only in a few other places. Computers became popular in smaller facilities and clinics at the same time, they became popular with the general public. Change became much more visible with the internet, and the internet became an essential tool for recording and transferring medical records.
All public and private healthcare providers were required by the American Recovery and Reinvestment Act to demonstrate “meaningful use” of EMRs by January 1, 2014. According to HealthIT.gov, “meaningful use” would accomplish the following:
Improves quality, safety, and efficiency while decreasing health disparities
• Involve patients and families
• Improve care coordination and public health
• Protect patient health information privacy and security
Even though patient medical records are more comprehensive and accessible than ever, refinements and system upgrades constantly improve clinic workflow and doctor-patient interactions.
What’s the Distinction Between an EMR and an EHR?
An EMR contains comprehensive information and records of the patient’s history with one provider. In contrast, an EHR has all of this and is sharable among authorized providers, health organizations, and clinics.
An EHR goes beyond just one provider’s information and includes a comprehensive patient history that can be shared with all providers to help coordinate care for the patient.
EMR and EHR systems are both valuable tools for clinics; however, there are some critical differences between the two.