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Understanding EMR

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There is a lot of discussion in healthcare right now regarding, EMR.  EMR stands for Electronic Medical Record.  EMR may also be referred to as EHR (Electronic Health Record).  It is essentially the same thing.  The EMR is comprised of any form of electronic medical record, and it has been around for a long time.  Examples of electronic medical records include lab reports, clinic visits, billing data, radiology reports, nursing notes, admission summaries and much more.

The electronic medical record is essentially an electronic version of what was formerly placed in paper charts. However, many healthcare organizations still maintain paper charts in conjunction with the electronic records.   The records are stored in individual health organization system networks. Each time a patient visits a long term care facility, a hospital, or a clinic, the data is stored for review by nurses, doctors, and other staff.

Because of HIPAA, only certain individuals in an organization can look at electronic medical records.  The level of access to protected health information (PHI) is determined by a staff member's position in the organization.  Doctors are able to access patient information if they were directly involved in the patient's care.  This is true of nurses, as well.  During the course of treatment, multiple doctors and nurses may have participated in a patient's care, and thus were granted access to the electronic medical record.  Other individuals in a health care organization, may have access to nearly all patients' health information.  For example, a data analyst may have access to all billing data, or a quality director may be able to review any record for quality issues.

Several different systems exist for EMR.  The most recognized are Cerner, Meditech, McKesson. However, many other companies have joined the EMR game.  Those include GE Healthcare, Apple, Xerox, and multiple startups.  Like most of healthcare, the EMR is a multilayered, multifaceted, complex system.