Medical Record
Electronic Medical Record (EMR)
Electronic Health Record (EHR)
Personal Health Record (PHR)
Continuity of Care Record (CCR)
Electronic Patient Record (EPR)
Computer Physician Order Entry (CPOE)
Practice Management System (PMS)
A medical record, health record, medical chart, or patient chart is a systematic documentation of a patient's medical history and care. The term medical record is used both for the physical folder that holds information on each individual patient, and for the body of information that comprises the total of each patient's health history.
An electronic medical record is a medical record in digital format. Using an EMR system will give your practice a structured process for documenting clinical information. Most EMR solutions also offer the opportunity to receive critical information—such as formulary or drug interaction checks—at the point of care. Using an EMR typically facilitates (1) access of patient data by clinical staff at any given location, (2) accurate and complete claims processing by insurance companies, (3) clinical note composition, (4) prescribing, (5) scheduling, and (6) sending orders to laboratories and receiving and viewing labs.
We tend to use the term electronic health record as a synonym for electronic medical record. However, some industry observers draw a fine distinction, defining an EHR as more comprehensive than an EMR. AC Group, for example, states that an electronic medical record system is basically just a system for charting patient counters electronically. By comparison, an electronic health record system includes much more functionality, particularly online functionality. According to AC Group, an EHR system—in contrast to some EMR systems—will have real-time clinical decision support, automated claims coding, drug interaction alerts, formulary checks, and access to a national medical knowledgebase. A robust EHR system will also have interfaces to multiple practice management systems, a patient portal where patients can perform their own health tracking, interoperability with other EHR and EMR systems (typically via HL7, the industry’s standard interface), and the ability to be customized for practices in multiple specialties. We believe the market is beginning to demand all of these features, and that most EMR products will, in the end, be EHR products anyway—thereby eliminating the need for distinguishing between the two.
Broadly defined, a personal health record is the documentation of any form of patient information–including medical history, medicines, allergies, visit history, or vaccinations–that patients themselves may view, carry, amend, annotate, or maintain. Today, when we refer to PHRs, we typically mean an online personal health record–which may variously be referred to as an ePHR, an Internet PHR, an Internet medical record, or a consumer Internet Medical Record (CIMR). Generally, such records are maintained in a secure and confidential environment, allowing only the individual, or people authorized by the individual, to access the medical information. Not all electronic PHRs are Internet PHRs. PC-based PHRs may be set up to capture medical information offline. And portable-storage PHRs are gaining in popularity. Although any storage device–including CD ROM, DVD or smart card–may be used, the USB flash drive seems to be the fastest growing. Patients may use a so-called “thumb drive” as a keychain, enabling them to carry their information wherever they go. A typical PHR will contain a full set of demographic and medical data, as well as information on the individual’s physician, emergency contacts, and advance directives. It may also include home test results, images, or medical instructions for the patient. Such a record is especially useful in emergency or travel situations.
The continuity of care record is a standardized electronic snapshot of a patient’s medical, insurance, and demographic information at any given point in time. Standardization was established by the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), other medical societies, and vendors and others in the healthcare informatics industry. Data are transmitted in XML, a standard transmission language, enabling a patient’s CCR to be shared among any number of providers. Each provider may make additions or changes to the information in a patient’s CCR, which is kept up-to-date in real time. While not all of the patient’s information is in the CCR–distinguishing it from most full-function electronic PHRs–critical information is available that may be useful in referrals, travel situations, and emergencies.
The term electronic patient record is seldom used and never defined. We present it here because of the prominence of the annual conference titled Towards the Electronic Patient Record (TEPR), sponsored by the Medical Records Institute. We believe EPR should have the broadest meaning possible: it should include any form of patient information stored in any electronic medium. That is, it should include EMR, EHR, PHR, and CCR. As the MRI has identified, the trend is clearly towards increasing use of EPR–but it remains to be seen which information formats and technologies ultimately will dominate use by caregivers and patients.
Computerized physician order entry is a process by which a physician creates a digital file giving care instructions for a patient. These instructions may be used as a reference for dispensing medications, ordering laboratory tests, or making referrals. Numerous studies have revealed dramatic benefits from CPOE in reducing prescription and other errors. As with EMR and EHR systems, a CPOE system may include decision support tools, such as dosage or drug interaction alerts.
Practice management software is now used by more than 90% of medical practices. Typical PMS features manage patient demographics, appointment scheduling, and billing. Most PM systems automatically maintain lists of insurance payers, generate and send requests for payment, and produce billing and payables reports.