Electronic medical record (EMR)

Electronic Medical Record (EMR) is a computerized record or data stored electronically, here data means patient information including insurance details, patient past medical history, genetic history, lab reports, ultrasound report, CT report, all the medical reports, and referral from Primary Care Physician (PCP) almost all the patient related documents that will be stored in EMR for further reference. Instead of paper documents now all the hospital and clinics preferred to keep electronic document because of cost effective and it reduce timing in searching for paper documents.

In the United States, 38.4% of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2008.

 EMR in US

Electronic medical records, like medical records, must be kept in unchanged form and lawful by the creator. Under data protection law, responsibility for patient records is always on the creator and who is having the record, usually a health care practice or facility. According to HIPAA the patient has a right to view the originals, and to obtain copies under law.

 EMR Uses

Even the federal government thinks electronic record keeping is important, But efficiency isn't the only benefit. For individual patients, access to good care becomes easier and safer when records can easily be shared. Important information, such as blood type, prescribed drugs, medical conditions and other aspects of our medical history,can be accounted for much more quickly. At the very least, an existing electronic medical record (EMR) can save time at the doctor's office. Quick access to our records can be lifesaving if an emergency occurs and answers to those questions are needed during the

Another benefit is safety. In the past, the way a doctor obtained your health history was by asking you. Each time you visited a new doctor's office, you filled out forms about your present & past history, including previous surgeries, or the drugs you take on a regular basis. If you forgot any information or if you didn't write it down because you forget at the time, then your doctor didn't have that medical information to work with.

When physicians share records electronically, your new doctor only needs to ask your name and DOB. He can get all your records from their electronic storage space. All of the information will be there in full. When it comes time to diagnose you, it might be important to him to learn that you are taking some kind of medication, that will make you comfort your time and physician’s time as well.

Money is saved by using electronic medical records, not just a paper and pen also lots of time will be saved and physician can use that efficient time with other patient or with family

EMR Format

In early 2000 storage was in just scanned documents like graphic or a just a pdf format, after 2000 there was a drastic change in EMR storage, documents are more basically e-formatted

The federal government has defined EMR into four functions:

1)      Computerized orders for prescriptions

2)      Computerized orders for tests

3)      Reporting of test result

4)      Physicians notes

Limitations of Electronic Patient Record Keeping

EMR has a few limitations. From storage to accessing the documents but the good news is every day we have access for new technology.

Data Security

Security is potentially a major problem. It’s not an easy task to create a system with 100% secure from hackers.
HIPAA and federal law, determines privacy of patient informatio