What is an Electronic Medical Record and what does it mean to me?
What is a medical record?
First, we need to understand that a medical record is the documentation of your health history. It contains notes your doctor has written, test results, medications, telephone messages and other important and personal information about your medical history. In the past, these records were kept in a paper folder which was then stored at your doctor’s office. It was the major communication and documentation tool to record the care you received.
What is an Electronic Medical Record (EMR)?
Electronic medical records contain the same information as your paper record but in an electronic form. This information is accessible to your health care providers through computers located throughout the Medical Center.
What are the Advantages to having an EMR?
There are many advantages to having an electronic medical record:
- Physicians and nurses have more time to spend with patients. With a paper record, healthcare professionals spend as much time performing administrative tasks as caring for patients. Too much valuable time is spent searching for and waiting for information in a paper-based system.
- Your health information is up-to-date. There is no delay as hand-written notes wait to be transcribed. Test results and all of your medical history are recorded directly into your EMR.
- Improved legibility, accuracy and completeness. With an EMR there is less potential for medical errors as well as improved quality and safety in patient care. There is no substitute for having accurate information about a patient’s condition and medical history immediately accessible.
- Allergies and adverse drug reactions are prominently displayed
- Reminders are activated when certain health maintenance tests and/or procedures are due
- Your prescriptions are electronically ordered directly to your pharmacy
- EMR permits more than one user to access your record at the same time. Example: While the nurse documents your vital signs and reason for visit, the provider can simultaneously review your chart prior to seeing you.
Are Electronic Medical Records Secure?
While people sometimes worry about the security of electronic records, they actually are much more secure than a paper record. With an electronic medical record, access is limited to staff who have a legitimate “need to know” for treatment, payment or operations purposes and activity is monitored on a regular basis. All access to the EMR is controlled through individual user passwords. The added benefit of this password access is that staff and providers can have different levels of access to the EMR as determined by their position. For example, receptionists do not have access to patient medical information, whereas nurses and medical assistants do.
In addition, electronic medical record systems are designed to prevent unauthorized users from gaining access to patient records through safeguards such as firewalls and other physical security measures.
Keeping patient information secure also involves making provisions for backups and disaster recovery of data. Backups provide additional protection against loss through fire, water damage, etc.
So… what does EMR mean to you?
Simply put, it means higher quality care to you… OUR PATIENTS!