An electronic medical record(EMR), also known as an electronic health record(EHR) or Computerized Patient Record (CPR) is a patient's medical information in an electronic format. This medical information is accessible via computers on a network, to provide health care and health-related services.
EHRs contain information regarding the past, present, or future physical and mental health of a patient, medical test reports, medical images, financial and demographic information. In addition, the ordering of medical tests, medications, treatments, and clinical guidelines are accessible within the EHR. The data contained in HER can be captured or transmitted securely and in real-time by users at the point of care. The three core functions of an Electronic Medical Record (EMR) are the following:
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EMR systems capture patient data
EMR systems are designed to capture data at the point of care using databases, rules engines, and knowledge bases. The information is then culled and submitted to the system via a computer workstation, tablet pc, mobile device or voice recognition system.
EMR software integrates with other data sources
The EMR must be capable of integrating with systems including financial, administrative, and clinical departments, as seen with many practice management systems. This allows more streamlined workflow reducing time spent entering data across multiple systems. It also ensures quality data across the systems. An example would include integration between a hospital, billing, laboratory, imaging, pharmacy, and practice management systems. A standard has been put in place call the HL7 (Health Level 7) which is a common language for sending and receiving messages from different information systems. The most common use is between a practice management and EMR system or between physician offices and a hospital.
EMR assists provider decision making
Rules engines can provide alerts, reminders, clinical protocols, and coding assistance at the point of care in EMR systems. EMRs can provide real-time data to a provider allowing providers to analyze and report data quickly. The data can also be compiled to include clinical statistics analysis, population health, patient/drug reports, and demographics reports.
What is an Electronic Medical Record (EMR)? CARE IMPROVEMENT PLUS PROVIDER PORTAL
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