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An electronic medical record (EMR) is a digital medical record that either originates from an electronic format or is converted from paper or hard copy to an online version. An EMR includes information about a specific patient, including:
- Patient contact information, including emergency contact(s)
- Vitals, such as height, weight, body mass index (BMI) and body temperature
- Past and future medical facility appointments
- Physician orders
- Prescriptions
- Medical progress and surgical notes
- Consent to release information forms
- Allergies
- Past medical history
- Billing information, such as insurance
- Discharge summaries and treatment plans
An EMR is also known as an electronic health record (EHR).
Techopedia Explains Electronic Medical Record
The push for paperless health records is more than a technological advancement. It originated with the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted by President Obama in 2009, and legislated as part of the American Recovery and Reinvestment Act of 2009 (ARRA), or Stimulus Act, which allocated $36.5 billion for the health care industry to convert electronic medical records (EMR) from paper to electronic form. This includes funds to hire EHR/EMR vendors and specialists and provide incentives to Medicare and Medicaid providers moving toward EMR implementation. As EHR implementation is enforced, future incentives will be made available to EMR providers. The implementation deadline for medical data conversion is 2015.
EHR advantages are numerous. A key reason is the notion that EHRs can save lives by reducing human error. For example, if physicians and nurses have crucial electronic medical information at their fingertips, fewer delays are expected in emergent treatment and critical care. EHRs are also convenient to patients, with the elimination of the repetitive process of divulging medical histories to new caregivers.
Confidentiality laws, however, need further exploration, and EHR security may need to be fine-tuned, especially in terms of behavioral and substance abuse records. Another problem is EHR implementation in smaller medical practices with little or no IT support.
