EMR, EHR? IDK!
Can you interpret electronic records?
The speed of change in medical record keeping was incredible the last decade!
The American Reinvestment & Recovery Act included measures to reform infrastructure, such as the Health Information Technology for Economic and Clinical Health Act (HITECH).
Electronic health records (EHRs) went from cutting edge, to fundamental.
HITECH supported electronic health records – meaningful use (EHR-MU). Guided by Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health IT, HITECH proposed meaningful use (MU) of interoperable EHRs as a critical national goal.
Do you understand meaningful use?
Meaningful Use (MU) was defined by use of certified EHRs in a meaningful way (for example electronic prescribing); ensuring certified EHRs connected in a manner that provided electronic exchange of data to improve quality of care; and when using certified EHRs, providers submitted data on quality measures to Secretary of Health & Human Services.
CMS granted incentive payment to eligible professionals or hospitals, who demonstrated efforts to adopt, implement or upgrade certified EHR technology, which prompted many health care organizations to action.
What is this EHR you speak of?
EHRs were not new, but they were sophisticated and required change; their adoption was slow. MU incentive pushed defining EHRs. Results were more standards, delivery mechanisms, and hardware.
EHRs embodied change in charting habits, supported how medicine was practiced, and achieved improved cost and quality.
EHR was not a simple computer application. It signified a sensibly created set of elements, highly integrated, requiring time, money, procedure modification, and reengineering of human dynamics.
EHR was an ongoing program, where constantly changing clinical knowledge required maintenance of electronic records. Understanding EHR was not simple.
I thought that was an EMR?
Even with advancement in implementing EHRs, there continued to be jumbled terminology. It resulted from force of habits, or maybe reluctance to change. In facilities the term electronic medical record (EMR) was used for systems based on electronic management systems.
Facilities expressed they had EMRs and EHRs, referring to systems that were template based for structured data entry. Physicians often used the term EMR to label systems in their offices.
The government adopted the term EHR. EHR was a data system framework, not a single application.
The National Alliance for Health Information Technology developed definitions:
EMR: electronic record of health-related information on an individual created, gather, manage, and consulted by authorized clinicians and staff within one healthcare organization.
EHR: electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
Have you reviewed medical records for your healthcare-related cases in the past?
Are you still reviewing medical records?
EHRs are voluminous. Times have changed. Nurses notes have gone by the wayside. Data is difficult to find and understand in the new EHR systems. The facilities and physicians do not even always understand what they are looking at. We do. Nurses work with them every day.
Bring a legal nurse consultant’s electronic record expertise to your legal team.
We speak EHR!
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Amatayakul, M.K. (2013) Electronic Health Records A Practical Guide for Professionals and Organizations. Chicago, IL: AHIMA