New technological capabilities have expanded medical care in creative ways. One area that has benefited from advances in communication and data technology is the storage of medical records. Before EMRs or electronic medical records, doctors and nurses kept records as print copies in secure storage facilities. EMRs allow clinicians and support staff to access their information in new and enhanced ways that were previously not possible.
Electronic Medical Records
An electronic medical record, or EMR, may seem as though it would be complicated to work with due to the need to access it over a computer. However, EMRs provide plenty of benefits to providers and patients, as well as come in a variety of software options.
Definition of Electronic Medical Records
Electronic medical records (EMR) software automates the documentation, storage, and retrieval of patient records.
EMRs improve access to information for doctors, nurses, and patients. Because of the ability to restrict access via passwords and biometric scanners, the records become more secure. With the recent uptick in EMR usage, there are services available to transfer old paper chart records into digital files that can be uploaded to an EMR platform.
Overall, EMR software records digital data that can track and monitor patient health over a long period. EMRs also offer the ability for files to be reviewed remotely I.e. clinicians can review data even when off-site, multiple people can review a chart simultaneously and there is no concern about handwriting or other confusions that can occur with paper charts.
How Is This Different From an EHR?
An electronic medical record (EMR) should not be confused with an electronic health record (EHR). While both systems have similar uses and capabilities, they are not wholly interchangeable for the needs of physicians. EHRs, or electronic health records, focus on total health. This broader view of a patient’s medical information is generally not stored on an EMR. Patients cannot take their EMR with them if they move to a different hospital, clinic, or physician outside of their current network.
EMRs help medical offices keep better, more secure records through digitization. Unlike with EHR software, electronic medical records do not have easily transferrable data. An EMR, however, comes with lower costs and fewer challenges compared to more rigorous EHR software systems.
The decision to choose an EMR over an EHR depends on what functions are most useful to a hospital, office, or clinic.
Key Functions of EMRs
Electronic medical records expand how physicians and clinicians can record and use information about their patients. By putting paper records into digital software, hospitals and clinics have better control over health data.
EMRs have a few key functions for both medical professionals and their patients.
- Charting: Medical history and diagnoses automatically enter a secure, digital space to be recorded. There are no longer many charts floating around from multiple visits. Plus, digital records are more accurate and clearer to read. Messy handwriting is a thing of the past.
- Patient Portals: Patients have direct access to their medical information with EMRs. Most electronic medical record software offers an online portal where patients have secure access to their past visits, medication history, and lab results from a particular hospital or clinic.
- E-Prescribing: Pharmacies receive prescriptions with the e-prescribing function of most EMRs quicker than before. This function can also send notifications about dosage amounts, allergies, and potential drug interactions to physicians.
- Order Entry: EMRs make it easier for providers to store and send orders for lab tests and more. There is less of a chance that orders will get lost in the shuffle of paperwork. Additionally, errors filter out of the system before they can cause problems. Hospitals and patients save time and money in the long term without duplicate tests.
- Decision Support: Along with the handy patient portal, most EMRs have functions that help patients manage certain aspects of their healthcare. Patients receive alerts and reminders about scheduled treatments, as well as recommendations for particular procedures.
These recommendations may arise from data about a patient’s demographics or their specific conditions. For example, women of a certain age will receive a reminder to schedule a mammogram with their provider if they have not already done so.
Benefits of EMRs
EMRs offer a wide range of benefits for medical providers. The following is not an exhaustive list but provides a picture of the potential improvement in patient care and record management with the adoption of EMR software.
Improved Patient Care
- Doctors using EMRs can see patient information in different ways than with the traditional paper record. In the long run, patients can expect to have better health outcomes. EMRs can turn health data, such as weight, cholesterol levels, and blood pressure, into useful charts. Better information over time allows physicians to screen for potential health issues or manage previous diagnoses.
- EMRs also improve patient care by forging stronger relationships between providers and their patients. When a patient has clear information about their medical history and overall health, they can become better advocates for themselves and have a more trusting relationship with their doctor.
- EMRs allow providers to see a picture of a patient’s history with their clinic or office. This picture is fundamental to coordinate medication, treatments, and lab tests.
- Patients will also be able to access all of their medical records to coordinate care with other clinics, if necessary.
- EMRs enable hospitals and clinics to run more efficiently. They eliminate mountains of paperwork that administrative staff must file and store in a safe and secure location. And there is always the risk of a paper record being lost or accidentally destroyed.
- EMRs also prevent physicians from ordering duplicate tests that are unnecessary for their patients. This streamlining of information saves time and money for patients and providers.
- Also, EMRs help medical providers of all sizes better manage and share information in the long-term. Keeping good records of medical advice and treatments is a cornerstone of reputable medical practices. Patients can expect their doctors to share information quicker, as well as to alert them to potential issues or changes in their care.
Reduced Medical Errors
Electronic records assure doctors and patients that the information they have is the most accurate and up-to-date. An EMR reduces medical errors by removing the risk of inaccurate data. Paper records can be lost or illegible, which could result in a misdiagnosis or an improper prescription. Electronic records also aid providers from ordering a medication that could be potentially harmful. Medications with similar chemical constructs that may not trigger an interaction in the provider's memory.
As there are downsides to everything, there are some things to take into consideration with any EMR software system.
The security of medical information stored online is a top issue for physicians looking to adopt an EMR software system. As EMRs have become more commonplace, the software used to record and store digitized records has become safer. You should be aware of the technologies and policies used to keep information secure before investing in any EMR software.
Trying to convince physicians to change from paper to electronic medical records can be a challenge. Overall, training is essential to encourage the widespread adoption of EMR software in a hospital or clinic. It is important to emphasize the benefits of electronic medical records to physicians and NPs who may be unsure about using them.
The main drawback of most EMR systems is the lack of interoperability. Interoperability refers to the transfer of patient data between systems. Data transfers can range from challenging to impossible, which makes it hard for a primary care doctor to refer their patients to specialists. However, EMR software is an ever-evolving area of technology. In the future, there will most likely be more methods to share information between doctors using different EMR software.
There is also usually a period of time when the system goes down for maintenance or there is an internet or power outage. The sensitivity of computers and the reliance on them is a factor that can cause problems throughout their usage.
Any hospital or medical care provider can readily adopt electronic medical records for their facility. Several EMR software options are available for consideration. Ultimately, the right software depends on the needs and abilities of individual medical providers.
1. Cloud-Based EMR Software
A cloud-based EMR software allows data to be accessed online. Remote access to information is a primary feature of a cloud-based EMR software. Medical information about patients is stored securely “in the cloud.” Because servers do not host data, cloud-based software can be a more affordable EMR option. These types of systems are also known as Web-based or Software-as-a-Service (SaaS).
2. Mac EMR Software
Mac EMR software, as can be assumed by the name, includes software compatible with all Apple devices. There are Mac-native options, which are designed exclusively for the Mac operating system. There are also cloud- or web-based software options that run optimally on any Apple device with access to the Internet.
3. ONC-Certified EMR Software
ONC-certified EMR software refers to any software that meets requirements set by the Office of the National Coordinator for Health Information Technology (ONC). These requirements focus on the proper management and storage of sensitive patient data.
ONC-certified EMRs are software that is tested by bodies authorized by the ONC for testing and certification. Testing ensures that software meets criteria set by the ONC for the meaningful use of health information. These criteria include patient portal access, a place to create care plans, quality reporting methods, and more.
4. Behavioral/Mental Health EMR Software
EMRs for behavioral and mental health providers offer a different range of features. These features are more specific to the needs of mental health clinics, therapists, and group clinics. For example, accessing old notes can be a time-consuming task for a therapist or mental health clinician. Advanced note management features on behavioral/mental health EMR software make accessing notes a more efficient process.
5. Medical Billing Software
Processing patient statements and insurance claims can be more manageable with medical billing software. There are software systems that integrate with EMRs to form a complete and robust administrative department.
Medical billing software offers medical providers a way to automate different billing tasks, including verifying insurance, processing claims, and payments, and following up on denied insurance claims. Frustrating administrative tasks become automatic processes done efficiently. The automation of information with EMRs frees up administrative personnel for more patient-facing responsibilities.
Electronic medical records are a rapidly-changing area of technology. For many physicians and healthcare providers, EMRs represent a means to improve the quality of their medical care. EMRs allow both doctors and patients to access records with ease and efficiency.
While not as expansive a system as EHRs, electronic medical records have numerous benefits to patient health outcomes. Patients and doctors can track data over time and schedule preventative appointments, manage medications, and monitor chronic illnesses. Most EMR software includes features for charting, e-prescribing, and order entry. Patients often have access through an online patient portal and access to decision support for regular medical reminders.
EMR software is not a one-size-fits-all solution for any medical provider. There are several types of EMR software, and it is up to individual providers to consider the best functions for their needs. An EMR can revolutionize the storage and access of medical information in meaningful ways, especially when the optimal software is selected.