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Electronic Medical Record Features. Electronic Medical Record Definition. An Electronic Medical Record is a computer based information system that includes data and functionality with the following characteristics.
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Electronic Medical Record Features
Electronic Medical Record Definition An Electronic Medical Record is a computer based information system that includes data and functionality with the following characteristics. • Provide secure, reliable and real-time access to patient health information where and when it is needed to support care. • Capture and manage episodic and longitudinal electronic health record information. • Function as clinicians’ primary information resource during the provision of patient care. • Assist with planning and delivering evidence-based care to individuals and groups of patients. • Support continuous quality improvement, utilization review, risk management and performance management. • Capture information necessary for reimbursement. • Provide longitudinal, appropriately masked information to support clinical research, public health reporting and population health initiatives. • Support clinical trials. As defined by HIMSS (July 9, 2003)
Order Entry Data Dictionaries Order Management Clinical Data Repository Order Communications Results Reporting Clinical Documentation Drug Database Clinical Pathways Customer Relation Management Clinical Decision Support Interfaces Electronic Medical Record Key Components EMR Data Types • Lab Results • Radiology Reports • Radiology images • Medications • Operative Notes • E.R. Notes • Encounter History • Appointment • Scanned Order Scripts • Progress Notes • Therapy Notes • History & Physical • Allergies • Demographics • EKGs • Scanned Advanced Directives • Patient Lists As defined by HIMSS (July 9, 2003)
Electronic Medical Record Environment Healthcare industry experts recommend that all hospitals integrate several core EMR functions through a single product. Functionality that is recommended to be integrated into an EMR Functionality that can be interfaced or integrated
Electronic Medical RecordBenefits & Costs • Benefits • Reduction in time used documenting clinical encounters (enabling more patient visits) • Improvements in encounter coding (resulting in increased reimbursement) • Eliminating paper charts and their associated costs • Reduction in dictation and transcription costs • Reduction in time and effort to locate and assemble paper chart information • Automated charge capture • Lower malpractice & risk of embezzlement • Optimization in the utilization of non-physician providers • Elimination of duplicate data entry • Ability to attract caregivers through state-of-the-art systems and access to patient information • Increased patient satisfaction through improved patient care • Costs • Initial costs for the application, implementation effort, and computer hardware • Infrastructure costs associated with implementing and expanding the system • Additional technical staff to support increased complexity in the application and environment • Initial and ongoing training costs associated with set up and usage of the EMR • Ongoing maintenance costs for vendor support and system upgrades
Electronic Medical RecordImplementation Options - Advantages
Electronic Medical RecordImplementation Options - Disadvantages
Electronic Medical RecordElectronic Medical Record (EMR) vs. Electronic Health Record (EHR)