The medical record (EMR) is the original record of the whole process of diagnosis and treatment of the patient in the hospital, which contains the first page, the record of the course of the disease, the results of the examination and test, the doctor's orders, the surgical record, the nursing record and so on. Electronic medical record not only refers to the static medical record information, but also includes the related services provided. It is electronically managed information about an individual's lifelong health status and healthcare behaviors, involving all process information from the collection, storage, transmission, processing and utilization of patient information. The National Institute of Medicine defines an EMR as an electronic patient record based on a specific system that provides users with access to complete and accurate data, alerts, reminders, and clinical decision support systems.
Electronic medical records emerged with the networking of hospital computer management, the use of information storage media - CD-ROMs and IC cards, and the globalization of the Internet. Electronic medical records is the inevitable product of information technology and network technology in the medical field, is the inevitable trend of modernization and management of hospital medical records, its initial application in the clinic, greatly improving the efficiency of the hospital and the quality of medical care, but this is still only the beginning of the application of electronic medical records.
Electronic Medical Record (EMR, Electronic Medical Record), also known as the computerized case system or computer-based patient record (CPR, Computer-Based Patient Record). It is a digitized patient's medical record that is saved, managed, transmitted and reproduced using electronic devices (computers, health cards, etc.), replacing the handwritten paper medical record. Its content includes all the information of a paper medical record.
Electronic Medical Record (Electronic Medical Record, referred to as EMR) issued by the Ministry of Health, according to the "Electronic Medical Record Basic Architecture and Data Standards Electronic Medical Record" is defined as: electronic medical record is a medical institution to the outpatient, inpatient (or health care object) clinical diagnosis and treatment and guidance of interventions, digital medical services work records.
Electronic medical records are electronic devices (computers, health cards, etc.) to save, manage, transmit and reproduce the digitized patient medical records, replacing handwritten paper medical records. Electronic medical records have the initiative, complete and correct, knowledge associated with, timely access to such characteristics, is a medical institution of outpatient, inpatient (or health care object) clinical diagnosis and treatment and guidance interventions, digital health care services work records. What exactly is an electronic medical record, the academic community still lacks a unified understanding. According to the study, the ideal electronic medical record should have two functions:
1. Doctors, patients or other authorized persons, in need of any health data or related information about an individual, in any case can be complete, accurate, timely access to them, and can be accurately interpreted, in the need to maximize access to detailed, accurate and comprehensive knowledge.
2. The electronic medical record can take the initiative to make judgments based on the information and knowledge it possesses, make timely and accurate prompts and give the optimal program and implementation plan when the individual health status needs to be adjusted. The reason why it is called the ideal electronic medical record because these two functions seem simple, but the meaning is profound, and it is difficult to fully realize within a few decades.
3. The Ministry of Health, "electronic medical record basic structure and data standards (for trial implementation)" given the definition: electronic medical record is created by the medical institutions in an electronic way, save and use, focusing on outpatient, inpatient (or health care objects) clinical diagnosis and treatment and guidance intervention information data integration system. It is a complete and detailed clinical information resource that is generated and recorded in the course of the individual resident's visits to the healthcare organization. Electronic medical record has different titles in the international arena, such as EMR, CPR, EHR and so on. The connotations and extensions reflected by different titles are also different. Although people have the same or similar understanding of some of the basic characteristics that an electronic medical record should have, there is no consistent definition of an electronic medical record because the functional form of the electronic medical record itself is still under development. Representative definitions include:
Definition of CPR by the Institute of Medicine (IOM) [1]:
The electronic medical record is electronically managed information about an individual's lifelong health status and healthcare, which can be used as the primary source of information in healthcare replacing the paper medical record for all diagnostic, legal, and administrative needs.
Definition of an EHR by the American HIMSS Society [2]:
An EHR is a secure, real-time, on-site, patient-centered information resource that serves physicians. It assists physicians in decision-making by providing them with needed anytime, anywhere access to the patient's health record, combined with evidence-based medicine decision support capabilities.An EHR automates and optimizes physician workflows, bridging the communication and response blockages that can lead to delays in care and disconnectedness of care.An EHR also supports the capture of data that is not directly used in healthcare, such as billing, quality management, performance reporting, resource planning, public ***health disease surveillance and reporting, etc.
Definition of an EHR by the International Organization for Standardization (ISO) Technical Committee on Health Information Standards (C215) [3]:
An EHR is a repository of information about the health of a healthcare subject represented in a computer-processable format.
Although the definition of EHR varies from one organization to another, it basically describes it in terms of both the information content that an EHR should include and the functions that an EHR system should have.
In terms of information content, the more inclined view now is that EHR includes not only an individual's medical record, i.e., all the medical information of outpatient and inpatient visits, but also an individual's health record, e.g., immunization, health checkups, and health status. It is also argued that EHRs should include health information recorded by individuals in addition to information generated by professional medical and health organizations. In terms of time span, electronic medical records should cover the entire process of an individual from birth to death.
Functionally, electronic medical records emphasize the advantages of information technology to provide service functions beyond paper medical records. Although it is still difficult to accurately and concretely list the functions of an electronic medical record system, electronic medical records demonstrate their functional possibilities in several ways. In general, it can be summarized into three aspects: the function of recording, storing and accessing medical information; the function of using the medical knowledge base to assist doctors in clinical decision-making; and the function of information reuse for public **** health and scientific research services. These three aspects are only a high degree of generalization, there is a wide range of diversity and scalability in terms of specific functional forms.
HIMSS summarizes the functional characteristics of the EHR in eight areas [2]:
(1) provide secure, reliable, real-time access to a patient's health record whenever and wherever it is needed for medical care;
(2) capture and manage visit and long-term health record information;
(3) serve as a primary source of physician information source role;
(4) assisting in the development of treatment plans and the provision of evidence-based care for a patient or group of patients;
(5) capturing data for continuous quality improvement, utilization surveys, risk management, resource planning, and performance management;
(6) capturing patient health-related information for use in medical records and healthcare payment;
(7) providing longitudinal appropriately filtered information to support medical research, public *** health reporting, and epidemiologic activities.
(8) support clinical trials and evidence-based research.
Internationally, although EMR, EPR, CPR, and EHR are sometimes used interchangeably in terminology, they each emphasize a different scope of the EHR. EMR emphasizes more on electronic medical records and computerized business processes within the healthcare organization; EPR and CPR emphasize the integration of patient-centered medical information within the healthcare organization, including the integration of patient's episodes of care and hospitalization records; and EHR further emphasizes the integration of patient-centered medical information within the healthcare organization, including the integration of patient's episodes of care and hospitalization records. EPR and CPR emphasize the integration of patient-centered medical information within healthcare organizations, including the integration of patients' past medical visits and hospitalization records. With the development of the situation, the connotation of EHR is gradually becoming the same understanding of the electronic medical record ****.
In China, people generally only use the term "electronic health record" to express the different concepts mentioned above, with no direct distinction between several concepts. When discussing EHRs in the context of hospitals, the term refers to EHRs within healthcare organizations; when discussing EHRs in the context of regional healthcare informatization, the term refers to electronic health records.
In accordance with the aforementioned definition of electronic medical records, the realization of electronic medical records within the hospital is essentially a patient-centered computer informatization of the entire hospital, while the electronic health record is the informatization of the entire healthcare industry and regional information **** enjoyment. This shows that the development of electronic medical records will be a longer process.
Inside the hospital, the electronic medical record is not an independent system, it is built on the basis of the full development of various types of clinical information systems, clinical information systems constitute the source of information for the electronic medical record. As an important part of the clinical information system and the core component of the electronic medical record system, the doctor's workstation is both the information source of the electronic medical record and the most important carrier of the electronic medical record.
In order to mark and evaluate the development process of EHR, HIMSS Analytics divides EHR into seven stages [4]:
Stage 0: Some clinical automation systems may exist, but the three major auxiliary department systems of laboratory, pharmacy, and radiology have not yet been realized.
Stage 1: The three major clinical support department systems are installed.
Stage 2: The large clinical support departments feed data into a clinical data repository (CDR) and the CDR provides physicians with access to extract and browse results. The CDR contains a controlled medical vocabulary and an initial clinical decision support/rules engine for conflict detection, and document scanning information may be linked to the CDR system.
Stage 3: Clinical documents (e.g., temperature slips, procedure sheets) are required requirements. Nursing records, treatment plan charts, and/or Electronic Medication Administration Record (eMAR) systems receive bonus points and are implemented and integrated with the CDR in the form of providing at least one in-hospital service. Initial decision support for error detection in medical order entry (i.e., drug/drug, drug/food, and drug/test conflict detection typically applied in pharmacy) is implemented. Some level of medical image access via PACS becomes a reality, accessible to physicians outside of the radiology department via an internal Intranet or other secure network.
Stage 4: Computerized physician order entry (CPOE) systems are added to the nursing and CDR environments, accompanied by a second level of clinical decision support capabilities based on evidence-based medicine. This stage is reached if a patient service area has achieved CPOE and has reached the previous stage.
Stage 5: The closed-loop medication administration environment has been fully realized in at least one patient service area. Electronic medication administration records (eMAR) and barcodes or other automated identification technologies, such as RFID, are implemented and integrated into the CPOE and pharmacy systems to maximize safety during patient medication administration.
Stage 6: Complete physician paperwork (structured templates) is implemented in at least one patient service area. Tertiary clinical decision support provides guidance on all physician activities, which is provided in the form of variable and compliance warnings, related to protocols and effectiveness. A complete PACS system provides physicians with medical images via Intranet, replacing all film-based images.
Stage 7: Hospitals have a paperless EMR environment. Medical information can be easily ****enjoyed through electronic transactions or exchanged with all entities within the regional health information network (i.e., other hospitals, outpatient clinics, subacute settings, employers, payers, and patients). This phase allows HCOs to support true EHRs as ideally modeled.
Gartner has also created a generational model for EHRs [5], which the organization divides into five generations:
The first generation, known as the collector, is a relatively simple system that creates a Clinical Data Repository (CDR), where information from multiple sources (e.g., testing and pharmacy systems) can be synthesized into one.
The second generation, called documenters, simplify documentation and provide access to clinical data.
The third generation, called assistants, provide limited decision support capabilities and cover both outpatient clinics and wards.
The fourth generation, called colleagues, provides advanced decision support capabilities and extends beyond outpatient clinics and wards.
The fifth generation, called mentors, supports continuity of care and progresses from decision support to practical guidance. The significance of the development of electronic medical records compared to paper medical records is at least the following:
(1) Providing healthcare professionals with complete, real-time, anywhere, anytime access to patient information helps to improve the quality of care.
(2) Combined with the application of medical knowledge base, medical errors can be effectively reduced by means of calibration, alarms and prompts.
(3) Through electronic information transmission and **** enjoyment, it can optimize the internal workflow of the hospital and improve work efficiency.
(4) It provides data sources for medical management, scientific research, teaching, and public **** health.
(5) To support the continuity of patient care between medical institutions through medical information ****sharing.