Electronic medical record

Electronic medical record (EMR) is a digital version of a patient's paper chart. EMRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

Overview

An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to:

• Track data over time
• Identify patients who are due for preventive visits and screenings
• Monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings
• Improve overall quality of care in a practice

Components

The EMR includes information such as:

• Patient demographics
• Progress notes
• Problems
• Medications
• Vital signs
• Past medical history
• Immunizations
• Laboratory data
• Radiology reports

Benefits

The potential benefits of EMRs include:

• Complete documentation of patient encounters
• Support for decision making
• Management of patient care
• Electronic ordering of tests and medications
• Electronic communication and coordination of care among members of a health care team and patients
• Patient access to personal health records, disease management tools, and health information resources
• Reporting and population health management
• Automated scheduling systems

Challenges

Despite the advantages, EMRs also have potential disadvantages and challenges, such as:

• Initial cost of setup
• Ongoing maintenance costs
• Changes in workflows
• Temporary loss of productivity leading up to implementation
• Technical problems
• Interoperability with other systems
• Privacy and security concerns

See also

• Health information technology
• Electronic health record
• Personal health record
• Medical practice management software

References

Electronic medical record Resources
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