what is an EMR - Electronic medical record

What is an EMR?

An EMR, or electronic medical record, is a medical record for a patient in a digital format that is stored on a computer or in a computer server. In health informatics, an EMR is considered by some to be one of the different forms of electronic health records, but usually these two terms mean the same thing. Sometimes EMR's include other information, such as HIT, or health information technology, which are systems that keep track of medical information, like medical practice management systems. These systems support the electronic medical records.

Until 2006, most medical practices still do not use EMR's or other health information technologies, like computer physician order entry systems, or CPOE's. In fact, less than 10% of the American hospitals have begun to use this technology, while only 16% of primary care physicians now use electronic health records. The majority of medical transactions in the US are still done on paper, with a system that was developed in the 1950's and is still in use today. The health care industry actually spends only about 2% of their gross revenues on HIT's, or health information technology, which is way behind other areas like finance.

One of the main problems of most medical facilities implementing EMR's is the interoperability for different medical offices and professionals to use the systems and software to communicate and exchange data accurately. In the US, the development of standards for EMR's is at the front of the agenda for national health care. Without a good interoperable EMR system, physicians, pharmacies, hospitals, and other medical professionals cannot share patient information correctly, which would be necessary for patient-centered care.

Since the EMR's need to be compatible, in 2004, President Bush created the Office of the National Coordinator for Health Information Technology or ONC, to address issues that deal with EMR's and interoperability issues to help establish a national health information network, or NHIN. This organization, along with the Center for Information Technology Leadership, has placed four different categories, or levels, of data that is in the health care data exchange right now. These different levels are:

Non-electronic data - this includes paper, mailed information, or phone calls.

Machine transportable data - this includes faxes and emails.

Machine organizable data - this includes HL7 messages, images, and objects.

Machine interpretable data - this includes automatically transferred lab results to an electronic health record.