Electronic Health and Medical Records - EHRs and EMRs

One Type of Digital Patient Health and Medical Record

electronic medical record
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Digital records kept by your doctor's office, your insurance company or the facilities where you are a patient, are called EHRs (electronic health records) or EMRs (electronic medical records). Both names are used interchangeably.

EMR/EHR systems were born out of Health Information Technology. They are intended to keep track of a patient's entire health and medical history in a computerized, electronic format.

By keeping these potentially vast records in this manner, they are more easily retrievable, and can make a patient's navigation through the healthcare system much safer and more efficient.

Before use of the EHR, records were kept on paper. Printed medical records are cumbersome to store and to access and are not easy to share among multiple providers. There can be long delays in incorporating new data into a paper medical record. They also pose a risk to the security of personal medical information, as only physical access is needed to read them.

Electronic medical records have not been adopted nearly so quickly in the US as one might expect. Lack of standardization and issues of security and privacy have stood in the way of their implementation.

Scanning of Paper Medical Records into the Electronic Medical Record/EHR

Electronic health records are comprised of two kinds of records. Older records, generally pre-2000, are usually scanned and stored in a graphic format or pdf.

These might include anything from doctors' notes to x-rays or other test results such as ultrasounds or MRIs. Since some of those records were recorded by hand, they can be hard to read and some may be illegible. Further, because of the processes used to shift from paper to digital records, or for recording new digital records, many mistakes were simply replicated, or even created by the digital conversion.

Native Electronic Medical Records

More recent records may be electronically native. That means they were never stored in any fashion except as a digital record. If your doctor records notes as you talk, or if you are issued a prescription from a computer printer, then your current records are being kept natively in digital form.

Four Functions of the EMR/EHR System

The federal government has defined a complete EMR system as containing four basic functions: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes. An individual doctor's practice, facility or insurance company's system determines on its own which of those records will be kept, making it more or less complete.

In 2009, as a part of the Economic Stimulus, the federal government began offering incentives to providers to encourage implementation of electronic health records. The incentives are in the form of rebates or reimbursements based on a set of criteria called Meaningful Use.

Other Forms of Digital Patient Records
Electronic medical records are not the only form of digital patient record. Patients may create their own PHR (personal health record). Hybrid systems are also in use. Learn about these records and how you can use them.

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