The document discusses electronic medical records (EMRs), defining them as digital versions of patients' paper medical charts that contain their medical history, diagnoses, treatments, test results, and other clinical data. EMRs allow authorized medical providers to securely access a patient's comprehensive medical record electronically. The document also outlines the key components, functions, and benefits of EMR systems, such as automating workflows, integrating with other healthcare IT systems, and facilitating data sharing across providers to support comprehensive patient care.

1. Electronic
Medical
Records
Dr. S. A. Tabish

2. What is EHR?
• An electronic health record (EHR) is a
digital version of a patient’s paper chart.
EHRs are real-time, patient-centered
records that make information available
instantly and securely to authorized users.
While an EHR does contain the medical
and treatment histories of patients, an
EHR system is built to go beyond standard
clinical data collected in a provider’s office
and can be inclusive of a broader view of a
patient’s care.

3. EHR
• ISO TC 215 defines an EHR as “a
healthcare record in computer
processable format.”
EHRs are a vital part of health IT and can:
• Contain a patient’s medical history, diagnoses,
medications, treatment plans, immunization dates,
allergies, radiology images, and laboratory and
test results
• Allow access to evidence-based tools that
providers can use to make decisions about a
patient’s care
• Automate and streamline provider workflow

4. Electronic Health Record (EHR):
• An electronic version of a patients medical
history, that is maintained by the provider
over time,and may include all of the key
administrative clinical data relevant to that
persons care under a particular provider,
includingdemographics, progress notes,
problems, medications, vital signs, past
medical history, immunizations, laboratory
data and radiologyreports.

5. Electronic medical record
• Should document history,
examination, diagnoses intuitively,
rapidly, efficiently
• Should automate tests, medication,
submission of diagnostic /
procedure codes
• Should include error checking rules
to avert allergies / cross reactions

6. Electronic Medical Record
• An EMR contains the results of clinical and
administrative encounters between a provider
(physician, nurse, telephone triage nurse, and others)
and a patient that occur during episodes of patient
care. Consequently, the EMR reflects the practice
style, job function, knowledge and skill of the
providers who create it. It necessarily includes data
structures and data elements that reflect those
providers' systems.
• The Institute of Medicine defined the basic functions of
an EMR, then known as the computer-based patient
record (CPR). The Institute of Medicine's definition
remains the gold standard

7. Electronic medical record
• Evaluation and Management (E
& M) electronic guidelines
should be built into the code
system
• Should be compliant with
HIPAA policies

8. EHR
• One of the key features of an EHR is that health
information can be created and managed by
authorized providers in a digital format capable
of being shared with other providers across
more than one health care organization.
• EHRs are built to share information with other
health care providers and organizations – such
as laboratories, specialists, medical imaging
facilities, pharmacies, emergency facilities, and
school and workplace clinics – so they contain
information from all clinicians involved in a
patient’s care.

9. EHR Scope
• EHR contain patient-level data collected during
and for clinical care. Data within the electronic
health record include diagnostic billing codes,
procedure codes, vital signs, laboratory test
results, clinical imaging, and physician notes. With
repeated clinic visits, these data are longitudinal,
providing valuable information on disease
development, progression, and response to
treatment or intervention strategies. The nearly
universal adoption of EHRs nationally has the
potential to provide population-scale real-world
clinical data accessible for biomedical research,
including genetic association studies

10. EHR System Functions
• Identify and maintain a patient record
• manage patient demographics
• manage problem lists
• manage medication lists
• manage patient history
• manage clinical documents and notes
• capture external clinical documents
• present care plans, guidelines, and protocols
• manage guidelines, protocols and patient-specific
care plans
• generate and record patient-specific instructions

11. Requirements of EHR
• EHRs must include the following assumptions:
• The relevant information of general interest should
always be present, easy to access and extract from
the general information. This is the case for both family
and personal histories that are kept and increase/are
added to over time so they can be used to inform
clinical decisions, regardless of where they take place.
• The limited temporal information generated in isolated
events may be well supported in closed electronic
documents. These documents may contain the
particularities of each specialty or service provided, in
terms of design and functionality, as part of each care
episode.

12. EMR Inter-relationships

13. Framework of EMR solutions

14. Stages of EMR complexity
1
2
3
0
eMAR
CDR is the central pivot

16. EMR – Nuesoft Xpress

17. ChiroChart EMR – MediPro

18. EMR frontscreen – MediNotes

19. EMR – FileMed

20. EMR – NextGen

21. EMR face sheet – AMBAS

22. EMR progress notes – AMBAS

23. EMR configuration – AMBAS

24. MedicsDocAsst EMR – ADS

25. MedicsDocAsst EMR – ADS

26. EMR – Medinformatix

27. RTS EMR – Customized page

28. RTS EMR – Electronic sign

29. Automated patient q’aire – ADS

30. MDA Int Medicine EMR – ADS

31. Cardiology EMR – MDS

32. Pediatric EMR – MDS Medical

33. Pediatric EMR – MDS Medical

34. Pediatric EMR – MDS Medical

35. Oncology EMR – Synergy

36. Oncology EMR (Patient chart)

37. Oncology EMR (Complaints)

38. Oncology EMR (Diagnosis)

39. Oncology EMR (Staging)

40. 3-D EMR Mapping Engine

42. ‘Bugle’ patient database – ARG

43. PMS – Nuesoft Xpress

44. PMS patient info – AMBAS

45. PMS scheduler – AMBAS

46. PMS online charge slip – AMBAS

47. PMS + EMR – MedInformatix

48. EPM appointment scheduling

49. Automated docu distribution

50. Accounts – Medinformatix

51. Collections – Medinformatix

52. Automated remittance module

53. ADS MedicsElite – PDA access

54. EMR data entry in PDA

55. Conclusion
• EMR is not about just installing
a few computers and storing
patient data
• EMR has to be integrated with
PMS / EPM
• EMR is all about automating
WORKFLOW process

56. Automated clinical workflow

57. Automated clinical workflow

58. Automated clinical workflow

59. Nature of big data in healthcare
• Electronic health record (EHR)
can empower progressed
appraisal and offer assistance
to clinical fundamental
organization by giving colossal
information

60. Conclusion
•EMR is ultimately geared
towards reducing errors,
improving safety and
care and cutting costs of
healthcare