Electronic Health Record (EHR), also called Computerized Patient Record (CPR) or Electronic Medical Record (EMR) relate to a patient’s medical record in an electronic format, accessible by computers on a network for the primary purpose of providing health care and health-related services. Although these terms are often used interchangeably, there is a distinct difference in the definition of each one. So which is the appropriate term? According to C. Peter Waegemann, CEO of Medical Records Institute, Electronic Health Record is a generic term for ALL electronic patient care systems. Computer-based Patient Record refers to a lifetime patient record that includes all information from all specialties (even dentist, psychiatrist) and requires full interoperability. Electronic Medical Record is a record with full interoperability within an enterprise (hospital, clinic, practice). Whatever you call it, the vision is of superior care through uniform, accessible health records.
Electronic clinical documentation systems enhance the value of EHRs by providing electronic capture of clinical notes; patient assessments; and clinical reports, such as medication administration records (MAR). Clinical benefits may be substantial – as much as 24 percent of a nurse’s time can be saved. 15 examples of clinical documentation that can be automated include:
- Physician, nurse, and other clinician notes
- Flow sheets (vital signs, input and output, problem lists, MARs)
- Peri-operative notes
- Discharge summaries
- Transcription document management
- Medical records abstracts
- Advance directives or living wills
- Durable powers of attorney for healthcare decisions
- Consents (procedural)
- Medical record/chart tracking
- Releases of information (including authorizations)
- Staff credentialing/staff qualification and appointments documentation
- Chart deficiency tracking
- Utilization management
Medical devices can also be integrated into the flow of clinical information and used to generate real time alerts as the patient’s status changes. For example, intravenous medication pumps connected to the clinical information system provide automatic dosage verification and documentation for medication management.
EHR workflow implications for healthcare clinicians (physicians, nurses, dentists, nurse practitioners, etc.) may vary by type of patient care facility and professional responsibility. However, the most cited changes EHRs foster involve increased efficiencies, improved accuracy, timeliness, availability and productivity. Clinicians in environments with EHRs spend less time updating static data, such as demographic and prior health history, because these data are populated throughout the record and generally remain constant. Clinicians also have much greater access to other automated information (regarding diseases, etc.), improved organization tools, and alert screens. Alerts are a significant capacity of EHRs because they identify medication allergies and other needed reminders. For clinical researchers, alerts can be established to assist with recruitment efforts by identifying eligible research participants.
As with any widespread implementation of new systems, electronic medical records have been hampered by many perceived barriers, including technical matters (system crashes, ease of use, lack of integration with other applications), financial matters and resource issues (training an re-training, initial costs for hardware and software, upgrades, replacement, resistance by potential users), security and ethical matters, confidentiality issues and incompatibility between systems. Further challenges include increased documentation time due to multiple screens and slow system response, decreased interdisciplinary communication and impaired critical thinking through the overuse of checkboxes and other automated documentation.
Whatever you choose to call it, EHR, CPR or EMR, the assumption is that physicians and nurses will obtain many benefits with the use of EMRs. Physicians will reduce duplicate tests by seeing what other physicians have ordered, they will view past visits to improve patient care, they will avoid legibility problems with other doctors’ handwriting and medical alerts will pop up to remind physicians of contra-indications. Likewise, nurses will have such benefits as eliminating duplicate order entries, more legible progress notes for nurses on succeeding shifts, less time documenting so that there is more time at the bedside and a more structured and organized note system for greater clarity.