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Electronic Medical Record Education Center

Portions of the content below were taken from Wikipedia, the free encyclopedia. See original article HERE

An Electronic Medical Record (EMR) is a computer-based patient medical record. An EMR facilitates

• access of patient data by clinical staff at any given location
  
  
• accurate and complete claims processing by insurance companies
  
  
• building automated checks for drug and allergy interactions
  
  
• clinical notes
  
  
• prescriptions
  
  
• scheduling
  
  
• sending and viewing labs

The term has become expanded to include systems which keep track of other relevant medical information. The practice management system is the medical office functions which support and surround the electronic medical record.

Although an EMR system has the potential to permit invasion of medical privacy, if security policies are monitored effectively EMRs are as secure as banking records, for example.

Electronic records fall under the purview of medical informatics, a combination of computation and computer science and medical record keeping.

According to the Medical Records Institute, five levels of an Electronic HealthCare Record (EHCR) can be distinguished:

• The Automated Medical Record is a paper-based record with some computer-generated documents.
• The Computerized Medical Record (CMR) makes the documents of level 1 electronically available.
• The Electronic Medical Record (EMR) restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems.
• The Electronic Patient Record (EPR) is a patient-centered record with information from multiple institutions.
• The Electronic Health Record (EHR) adds general health-related information to the EPR that is not necessarily related to a disease.

Standards

Though there are few standards for modern day EMR systems as a whole, there are many standards relating to specific aspects of EHRs and EMRs. These include:

• ASTM CCR_-_Continuity_of_Care_Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or Electronic Medical Record (EMR) systems, allowing easy interoperability between otherwise disperate enities.
  
  
• ANSI X12 (EDI) - Used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information.
  
  
• CEN - EN13606, the European standard for the communication of information from EHR systems, and HISA, a services standard for inter-system communication in a clinical information environment.
  
  
• DICOM - a heavily used standard for representing and communicating radiology images and reporting
  
  
• HL7 - HL7 messages are used for interchange between hospital and physician record systems and between EMR systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other material.
  
  
• ISO - ISO TC215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
  
  
• openEHR - public specifications and implementations for EHR systems and communication, based on a complete separation of software and clinical models.