Electronic medical record software are digital tools to manage a patient’s medical records. As with most digital platforms, EMRs bring a flurry of advantages over traditional paper charts.
EMRs allow doctors to track patient data over time, identify the patients that require special or immediate checkups, understand patient experience in certain situations, and improve overall care quality within the practice.
So, whenever a patient visits a clinic or interacts with the healthcare provider anywhere, the doctor or healthcare practitioner can simply look into their EMR and administer proper care for the patient.
The idea of EMR came to existence when Larry Weed, a physician, came up with a new way to organize patient records in his quest for a more organized approach to patient data.
Weed condemned the way of contemporary medical records in which, “facts and phrases are presented that suggest difficulties in many systems,” and complained that, “confusion in such a tangle of illogically grouped bits of information is such that one can not reliably discern how (or if) the physician defined and logically pursued each problem.” Source: National Library of Medicine
As a solution, Weed posited the use of structured medical records organized around defined clinical problems with a description of their development and relevant physical findings.
We will talk more about Weed’s approach to medical records and how it gave birth to modern EMRs later in this blog.
The Role of EMRs in Modern Healthcare
Today, EMRs are the backbone of the healthcare system. According to the CDC, 88.2% percent of office-based physicians use any EMR system.
Created in different departments and at varied timelines, EMRs offer multi-center and multi-user access to patients health records and play an important role in facilitating apt treatment service, follow ups, and remote care.
EMRs also help in detection and classification of diseases, improved clinical decision making, and refined efficiency in overall healthcare.
All in all, EMRs help establish transparency between patients and healthcare providers.
If we are to understand the significance of EMRs in modern healthcare, we must envision the healthcare scenario without ERMs.
How does that look?
Doctors and healthcare professionals are back to paper charts for taking notes and documenting patient experiences. The healthcare staff needs to comb through racks of paperwork to find the right chart for setting up appointments. Time and efficiency is lost as most staff is occupied with managing paperwork. Patients have to repeatedly express their situation to every healthcare professional they meet in order to clearly and effectively communicate the troubles they are facing.
Not a pretty picture, right?
EMRs have become an essential part of the modern healthcare industry. And according to the Office of National Coordinator for Health Information Technology, more than 90% of healthcare institutes have adopted some form of digital medical record system. This goes on to say that the healthcare industry has recognized the significance of EMRs and has developed the technology to better suit its unique needs.
EMR Key Features, Functionalities, and Benefits
While EMRs started as a tool for better note taking and patient data management, they have evolved to play a wider and more expansive role in the healthcare industry. This has been made possible through years of continued development that EMRs have gone through since their advent. Now, EMRs come equipped with a number of powerful features and functionalities that make healthcare easier and more convenient.
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Some of these features and functionalities include:
Patient Portal
The idea behind the patient portal is to give the patient access to their medical records and status. Think of it like a self-service where patients can access and review their personal health record, schedule appointments, pay bills, and even communicate with their healthcare provider.
Patient portals are an important part of the EMR as they enable streamlined workflows, increased efficiency, improved patient engagement, and reduce the chances of medical errors.
Appointment Management Integration
Another great advantage of EMR is its ability to integrate with the appointment scheduling system and enable easy appointment management. By automating the appointment scheduling, healthcare professionals can take off the administrative burden of manually scheduling appointments and can save time and effort that they can otherwise utilize in more productive things.
Appointment scheduling management not only allows the professionals to automate appointments but also allows patients to secure their appointment with their care providers. It also comes with an appointment reminder to help keep track of the due dates.
e-Prescribe
E-prescribing is when healthcare professionals use electronic systems to generate, transmit, and fill medical prescriptions. With ePrescription enabled EMR, healthcare providers can send prescriptions directly to a pharmacy electronically, eliminating the need for paper prescriptions.
The doctor or healthcare provider simply puts the details in the EMR and the same is automatically and securely transmitted to the patients’ preferred pharmacy, significantly reducing the chances of errors. The ePrescription can be updated at any given time through the EMR.
Moreover, with ePrescription, the most commonly used prescriptions can be added as favorites, allowing for quick pull-ups of the go-to medicines.
Charting
Charting is the process of recording patient information on file, including demographics, vital signs, diagnoses, allergies, medicines, lab test results, treatment plans, immunization dates, progress, and overall health assessment.
Such charts help create a systematic and organized documentation of the patients’ medical records. Charts can be edited in real-time, ensuring whoever has access to the EMR can access up-to-date patient information.
Here is a list of information typically included in medical charts:
- Demographics: Name, age, contact information, and other personal details.
- Medications: Current and past medications, including dosages and durations.
- Allergies: Known allergies and potential drug-allergy interactions.\
- Medical History: Comprehensive health history, including past illnesses and conditions.
- Family History: Health information of immediate family members, including causes of death and common familial diseases.
- Surgical History: Details of surgeries, including dates and outcomes.
- Social History: Information about current and past occupations, community involvement, and social activities.
- Developmental History: Records of motor skills, cognitive development, social and emotional growth, language development, and growth charts.
- Obstetric History: Number of pregnancies, outcomes, and any complications.
- Immunization Records: Dates and details of vaccinations.
- Habits: Information on drug use, smoking, alcohol consumption, sexual history, and other lifestyle factors.
Lab Integration
Lab integration with EMR simply means seamless connectivity between a particular lab and the EMR system in such a way that the lab results are updated on the EMR in real-time. Physicians can raise a ticket for lab tests using a web portal on the ERM and have the results updated on the same interface in due time. The electronic method helps minimize the chances of error.
Not to mention, lab integration with EMR also allows patients access to their reports through the patient portal.
CTI Integration
EMRs ability to integrate with telephony is one of the most sought after and important features that the system can offer. EMR CTI integration allows the healthcare professionals to be readily active and well informed while interacting with a patient. With CTI Integration, the EMR system provides ScreenPop and Click to Dial. The former helps the doctor stay up-to-date with the patient information as soon as they get on a call with them and the latter helps them connect with any patient with a single click.
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Reporting
Electronic medical record software also allows healthcare providers to create comprehensive reports of the patients. These reports include vital information about the selected patient in the chosen timeline.
There are a few different types of EMR reporting, namely wired reporting, parameter reporting, and data-intensive reporting.
Let’s look at them in further detail:
- Wired Reporting: Wired reporting usually focuses on one aspect of the facility’s patient care. These kinds of reports offer little to no customization and are basically the default report generated by the system.
- Parameter Reporting: These reports offer more customization and formatting options. Parameter reports usually contain real-time data, clinical notes, an order for medication, and other medical documentations.
- Data-intensive Reporting: Data-intensive reports are the most extensive out of all the reports. These reports can be generated with large datasets over extended time periods.
EMR Challenges
Every piece of technology has its drawbacks and EMRs are no different. Despite being one of the most innovative technologies at the helm of modern healthcare, EMRs tend to assert a set of challenges. Primarily, EMRs lack the functionality of interoperability. Interoperability is the ability to share patient data to other healthcare professionals digitally. Unfortunately, most EMRs lack interoperability, which can cause a one-sided treatment approach.
Moreover, the cost implication and learning curve are also some of the factors that can present as a challenge in EMR implementation. You can read more about the pros and cons of EMR in detail here:
Types of Electronic Medical Record Software
Alright, now that we have understood what EMRs are and how they function, it’s time we delve into the types of EMRs. Not all EMRs are made the same. Some EMRs work well in a smaller clinical setting while others are more suited for larger operations. Some cater to specific medical situations while others can be used more flexibly. EMRs also vary based on their deployment.
Let’s take a look at some of the types of EMRs:
⦿ On-premise vs. cloud-based EMR systems: The difference between on-premise and cloud is self-explanatory. Cloud-based EMRs are preferred due to their scalability and flexibility. Cloud-based EMRs take away the need for infrastructure maintenance and offer shorter deployment periods.
On-premise EMRs, on the other hand, provide complete control and security. They offer a high level of management and ownership over the system. Such kinds of Electronic Medical Record System also provide more customization options, allowing healthcare providers to curate the system as per their needs.
⦿ Specialty-specific vs. general-purpose EMR software: Specialty-specific EMRs are developed to cater to particular medical situations. These systems work on the unique processes, workflows, and medical needs of certain specialities. For instance, a speciality EMR for cardiologists will feature functionalities that are specific to the needs of cardiology.
General-purpose EMRs are generally suited to all the practices and come with basic features and functionalities that can be used across different medical domains.
⦿ Open-source vs. proprietary EMR solutions: Open-sourced EMRs have risen in the healthcare industry due to their flexibility and inexpensiveness compared to proprietary EMRs.
Nevertheless, the healthcare institute opting for open-source EMR still has to pay for hardware, infrastructure, and implementation cost.
Proprietary EMRs are more secure and robust. They come with depth of support, data options, customization options, and are more reliable compared to the open-sourced ones.
Factors to Consider When Choosing EMR Software
Electronic Medical Record software are no longer a luxury but a necessity for healthcare providers. And choosing the right EMR can make all the difference in how one provides healthcare. The idea of “the right EMR” may change as per one’s preferences and the tasks they seek to carry out with the software, nevertheless, here are a few general rules to consider:
⦿ Cost Considerations and Budgeting: First and foremost, you will need to figure out the amount of money that you are willing to spend both in short and long-term. As we mentioned above, you can opt for open-source EMRs to save cost. Nevertheless, it might levy a certain cost out of you in other ways. Proprietary EMRs also come in a range of prices that can both escalate and de-escalate based on the features and functionalities you are looking for.
⦿ User Interface and Ease of Use: Another important factor to consider while choosing the right EMR is the user-interface of the system. Of course, the user-interface preference will change from person to person. However, you must choose a UI that is easier to get used to and is user-friendly, regardless of who is using it.
Consider simple workflow, clear communication, and intuitive design while choosing an EMR.
⦿ Integration Capabilities With Existing Systems: Any EMR you choose will require you to integrate it with different systems in order to function at its best potential. EMR integration paves the way for better reporting, patient engagement, enabling department-specific features, enhanced billing, and much more.
⦿ Compliance With Healthcare Regulations (Hipaa, Gdpr, Etc.): Compliance with healthcare regulations is one of the most important factors to consider while choosing an EMR. Firstly, try to understand the regulatory requirements yourself and stay updated with the changing dynamics to ensure you are in sync with the compliance.
Next up, conduct a compliance audit on your preferred EMR. Assess the system’s security features, access control, encryption capabilities to make sure they align with the regulatory requirements.
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Pay special attention to patient data security. Implement privacy policies and procedures that define how patient information should be handled.
The Birth of EMR and What’s to Come in the Near Future
Despite having revolutionized modern healthcare practices with his efficient model of patient data management, Larry Weed remains fairly unknown.
This is mostly because his contribution to healthcare does not lay in identifying new diseases or devising better treatment. Larry focused on improving the more humdrum aspect of healthcare: the medical record.
Weed’s approach to organized patient record can be summarized with two abbreviations: SOAP and POMR. SOAP stands for Subjective, Objective, Assessment, and Plan and POMR stands for Problem-Oriented Medical Record.
SOAP was a method of documentation that was used to create patients’ charts, which eventually became an essential ingredient for POMR.
The Subjective section contains the patient’s own words about their symptoms and experiences.
The Objective section records measurable and observable data.
In the Assessment section, the healthcare provider provides their own personal opinion about what might be wrong with the patient.
Lastly, the Plan section outlines the next steps for the patient’s treatment.
Problem-Oriented Medical Record, unlike classic health records, focuses on the patient’s problem, their progress, and their relations between clinical events. This approach helps providers have a clear view of the patient history and have an orderly process to solve their issues.
The development of SOAP and POMR phenomena introduced the idea of using Electronic Medical Record to document patient information. Ofcourse, the earlier EMRs were nowhere close to the EMRs of today and had serious drawbacks such as lack of data privacy, connectivity issues, and more.
The earliest EMRs can be traced back to the 1960s. Backed by Larry Weed’s idea of organized note-taking and having a systematic approach to patient care, medical records and their management became an important part of the healthcare system.
The first full-fledged EMR was developed in 1972 by Regenstrief Institute. Due to being the first of its kind and bearing a high price tag, EMRs were not attractive to physicians. Nevertheless, the system was used in government hospitals and other visionary institutions.
In the 1990s when personal computers were on the rise, EMRs also developed to become much more competent and powerful versions of themselves.
The idea that Larry Weed brought to the healthcare industry has since evolved into the cornerstone of the healthcare industry.
Today, EMRs have gone beyond organized patient note taking and patient-oriented medical records to offer a much more comprehensive and detailed patient care service option.
In the coming years, interoperability and data exchange is going to get easier with EMRs. Moreover, the inclusion of AI and ML is also going to be an essential part of EMR systems. In fact, According to Grand View Research, the global AI in healthcare market is expected to grow from $22.45 billion in 2023 to $208.2 billion by 2030.
Another likely development that is to be introduced with EMR is the integration with IoT devices. EMR IoT integration will offer more personalized and improved patient care in real-time. Personalized care, remote monitoring, and early disease detection can all be a part of EMR systems with IoT integration.
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Conclusion
EMRs have come a long way since their inception and still have a long way to go. Larry Weed in his 2-part article titled “Medical Records That Guide and Teach” wrote “To deal effectively with [clinical complexity] it will be necessary to develop a more organized approach to the medical record,” and called for “a more positive attitude about the computer in medicine.”
And thus, EMRs came into existence.
Currently, any healthcare institute that aspires to remain relevant for the long run needs to implement EMR as their central operating system. Not to mention, EMR integration with third-party applications also play a major role in modern healthcare and help professionals make the most out of their EMRs.
