An electronic medical record (EMR) is a digital record of an individual’s health-related information created, updated, and managed by an authorized clinic
ians and their medical staff in a healthcare organization. These records are made with the help of web-based EMR systems like Epic and Cerner. These are simply platforms that make collecting, storing, and sharing patient records within the organization easier. After adding their patients’ information to the EMR, clinicians can access it conveniently through a computer or tablet and read their medical history to better understand their medical needs.
EMR systems are not an entirely new concept. They gained traction in the late 20th century with the development and mass adoption of computers. Before that, healthcare organizations still recorded patients’ health information for coordinating care. However, the records were paper-based. Specifically, clinicians recorded patient information in paper charts that contained these sections: face sheets (a brief overview of the patient with demographic and contact info)
, medical encounters (a record of visits to the clinician), and progress notes (clinician observations on the patient at every office visit). They also included sections for orders such as for X-rays or laboratory tests, the test results, and medication prescriptions.
EMR systems are essentially built on that paper charts model, maintaining
the critical data categories but transferring the process from paper-based to electronic. Modern systems enable clinicians to collect and record patient data in an orderly sequence with different tabs for face sheets, doctor’s notes, allergies, lab tests, and medications.
There are several advantages of using EMRs for both patients and clinics. For patients, the primary benefit is that they get to enjoy better care. Because doctors have convenient access to patient’s medical information, they can make more accurate diagnoses, track their treatment better, and make more informed recommendations for screening and preventive care. For patients living in remote areas who have to rely on telemedicine, their doctors can still recommend tests, receive digital submissions of results, and add them to their electronic records, informing better treatment decisions.
For clinics, adopting EMR systems means they make fewer recording errors, save space by doing away with paper records, and lower operating costs, since all patient data is in one place, accessible by the click of a button. Further, they can optimize workflow by trac
king patients and managing visits. EMR systems are also scalable and support interfacing with external healthcare systems like other hospitals, laboratory networks, and pharmacies. As such, clinicians can integrate concepts like e-prescriptions as part of care, minimizing the chances that pharmacies give the wrong drugs or doses because of a doctor’s poor handwriting. Electronic data is also less susceptible to physical damage, unlike paper charts, and hospitals can also back it up to protect against data loss.
Despite all these benefits, some healthcare providers lag in adopting EMR systems. These are mainly small practices and ambulatory care providers. Some of the reasons they have for not making the switch include high initial cost, lack of skilled personnel to implement and support the EMR systems, concern that the systems may become obsolete, and concern over technological issues like data privacy and security. These barriers are not insurmountable.
To address the cost barriers, practitioners can take advantage of government support initiatives. Over the years, federal and state governments have launched programs to facilitate greater adoption of interoperable EMR systems among practitioners. The programs generally incentivize adoption through grant funding, loans, and tax credits.
To get around concerns about data security, practitioners can choose EMR vendors who sell systems with built-in security measures to safeguard patient data. The vendors can also train staff on essential security measures.