EMR (Electronic Medical Records) & EHR (Electronic Health Records)
About Electronic Medical Records (EMR)
From Wikipedia 2010
An electronic medical record is usually a computerized legal medical record created in an organization that delivers care, such as hospitals, pharmacies and doctor's offices. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and manipulation of patient records.
Electronic medical records, like medical records, must be kept in unaltered form and authenticated by the creator. 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, pharmacy 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, has a right to view the originals, and to obtain copies under law.
Most national and international standards accept electronic signatures. 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."
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. Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from a EMR readily visible and accessible for consumers.
Some EMR systems automatically monitor clinical events, by analyzing patient data from an Electronic Health 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.
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 over 9000 payers, providers and other entities that handle providers' billing data have some access.
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.
The American Society of Consultant Pharmacists empowers pharmacists to enhance quality of care for all older persons through the appropriate use of medication and the promotion of healthy aging. The vision of the American Society of Consultant Pharmacists is optimal medication management and improved health outcomes for all older persons.Epic / EpicCare EMR
The EpicCare EMR is rated #1 in its category by KLAS Enterprises* – and has been for the last 10 years straight. The system makes physicians more productive by simplifying the important patient-facing elements of care delivery. EpicCare is a physician-friendly system in use by providers representing more than 100 specialties. It installs easily with our pre-built Model System and configures to meet specific workflow requirements. Instead of starting from scratch, Epic customers build on the content from successful customers – including decision support, order sets, reports and documentation tools. The result is a faster path to effective chronic care management and measurable quality gains.