Electronic medical record

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An electronic medical record (EMR) is a computerized medical record created in an organization across inpatient and outpatient environments that is used to document, monitor, and manage health care delivery within organizations such as a hospital or physician's office.[1] Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records.

Contribution under UN administration and accredited organizations

The United Nations World Health Organization (WHO) administration intentionally does not contribute to an internationally standardized view of medical records nor to personal health records. However, WHO contributes to minimum requirements definition for developing countries.[2]

The United Nations accredited standardization body International Organization for Standardization (ISO) however has settled on some standards in the scope of the HL7 platform for health care informatics. Respective standards are available with ISO/HL7 10781:2009 Electronic Health Record-System Functional Model, Release 1.1[3] and subsequent sets of detailing standards.

Privacy concerns

A major concern is adequate confidentiality of the individual records being managed electronically. According to a 2006 LA Times article, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and over 600,000 payers, providers and other entities that handle providers' billing data have some access.[4]

In the United States, this class of information is referred to as protected health information (PHI), and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws.[5]

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[6]

Technical standards

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

  • HL7 - message format for interchange between different record systems and practice management systems
  • ANSI X12 (EDI) - A set of transaction protocols used in the US for transmitting virtually any aspect of patient data
  • CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care
  • CEN - EHRcom (EN 13606), a standard for the communication of information from EHR systems
  • CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment
  • DICOM, a standard for representing and communicating radiology images and reporting

Interoperability towards sharing records

In the United States, the development of standards for EMR interoperability has been at the forefront of the national health care agenda at least since the mid-2000s.[7] Many physicians currently have computerized practice management systems that can be used in conjunction with a health information exchange (HIE), allowing for first steps in sharing patient information (lab results, public health reporting) which are necessary for timely, patient-centered, and portable care.

The future vision of many connected health systems is the ability to connect the electronic medical record system to an electronic health record, creating a shared and portable collection of a patient's health data. This sharing will have to include elements of granular permissions at the data type level and the ability for patient generated content to be "tagged," allowing the provider to maintain clinical integrity of information.

EMR vs. EHR

Consult this article for more about the comparisons between an "electronic medical record" (EMR) and an "electronic health record" (EHR).

Regulatory compliance

Regulatory standards and recommendations that may affect an EMR include:

Notes

An element or two of this article is reused from the Wikipedia article.

References

  1. Garets, Dave; Davis, Mike (26 January 2006). "Electronic Medical Records vs. Electronic Health Records: Yes, There Is a Difference". HIMSS Analytics, LLC. http://www.himssanalytics.org/docs/wp_emr_ehr.pdf. Retrieved 08 May 2013. 
  2. "Medical Records Manual - A Guide for Developing Countries" (PDF). WHO. March 2001. http://whqlibdoc.who.int/wpro/2002/9290610050.pdf. Retrieved 08 May 2013. 
  3. "ISO/HL7 10781:2009 - Electronic Health Record-System Functional Model, Release 1.1". ISO. 2009. 
  4. Foreman, Judy (26 June 2006). "At risk of exposure". Los Angeles Times. http://articles.latimes.com/2006/jun/26/health/he-privacy26. Retrieved 08 May 2013. 
  5. "US Code of Federal Regulations, Title 45, Volume 1, Section 164.501 - Definitions". U.S. Government Printing Office. 01 October 2012. http://www.gpo.gov/fdsys/pkg/CFR-2012-title45-vol1/xml/CFR-2012-title45-vol1-sec164-501.xml. Retrieved 08 May 2013. 
  6. "EU Directive 95/46/EC - The Data Protection Directive". Office of the Data Protection Commissioner. Archived from the original on 28 September 2007. http://web.archive.org/web/20070928142238/http://www.dataprivacy.ie/viewdoc.asp?m=&fn=/documents/LEGAL/6aii.htm. Retrieved 08 May 2013. 
  7. "CMS Strategic Action Plan 2006–2009" (PDF). CMS. 16 October 2006. Archived from the original on 21 January 2009. http://web.archive.org/web/20090121021249/http://www.cms.hhs.gov/MissionVisionGoals/Downloads/CMSStrategicActionPlan06-09_061023a.pdf. Retrieved 08 May 2013.