Electronic medical record

For information on shared or comprehensive computerised records in health care in enterprise wide systems see electronic health record

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An electronic medical record is usually a computerized legal medical record created in an organization that delivers care, such as a hospital and doctor's surgery.^[1] Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and manipulation of records.

Electronic Medical Records in the United States

Usage

In the United States, one-quarter of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2005,.^[2] However, less than 10% of these physicians actually have a "complete EMR system", with all four basic functions deemed minimally necessary for a full EMR: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes.^[3].

Legal status

Electronic medical records, like medical records, must be kept in unaltered form and authenticated by the creator^[4]. 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, owns the information contained within the record and has a right to view the originals, and to obtain copies under law.^[5]

Electronic signature

Most national and international standards accept electronic signatures.^[6] According to the American Bar Association, "A signature authenticates a writing by identifying the signer with the signed document. When the signer makes a mark in a distinctive manner, the writing becomes attributable to the signer."^[7]

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^[8]. Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from a EMR readily visible and accessible for consumers.

Event monitoring

Some EMR systems automatically monitor clinical events, by analyse patient data from an Electronic Medical 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.^[9]

GP2GP

GP2GP is an NHS Connecting for Health project in the United Kingdom. It enables GP to transfer a patient's electronic medical record to another practice, when the patient move onto the list of other practice^[10]

Privacy concerns

A major concern is adequate confidentiality of the individual records being managed electronically. According to the LA 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 600,000 payers, providers and other entities that handle providers' billing data have some access.^[11]

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.^[12]

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.^[13]

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:

• XML - a document format allowing easy interoperability.^[14]
• 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.[2] 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 health information exchange (HIE), allowing for first steps in sharing patient information (lab results, public health reporting) which are necessary for timely, patient-centred and portable care.

See also

• List of open source healthcare software

References