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Electronic Health Records Software

What is Electronic Health Record Software?

Electronic Health Record Software is a computerized system that creates and maintains an electronic medical record (EMR). This computerized medical record is usually created in an organization that delivers care, such as a hospital or physician's office. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records.
Most Electronic Health Record Software systems fail to interchange data easily which has hindered their adoption. This also causes problems in the industry as well often times requiring redundant data entry which causes errors and other problems.

Contrast to Traditional Paper based Health Records

Paper based records are still by far the most common method of recording patient information for most hospitals and practices in the U.S. The majority of doctors still find their ease of data entry and low cost hard to part with. While they are easier for the doctor to record medical data at the point of care, they also require a significantly more storage space compared to digital records and there is also the problem of physically securing them as HIPPA violations can be extremely harsh and expensive.

In the US, most states require physical records be held for a minimum of seven years. The costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media. When paper records are stored in different locations, collating them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. This also makes it extremely difficult for public agencies to rapidly track potential health risks, trends and potential epidemics.

Person-centered records compound this problem as they are impractical to maintain if not electronic (thus difficult to centralise or federate). When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records. Because of these many "after entry" benefits, federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic medical records. Congress included a formula of both incentives (up to $44K per physician under Medicare or up to $65K over 6 years, under Medicaid) and penalties (i.e. decreased Medicare/Medicaid reimbursements for covered patients to doctors who fail to use EMR's by 2015) for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.

One study estimates electronic medical records improve overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of only a few "unnecessary" tests or admissions.

However, the increased portability and accessibility of electronic medical records may also increase the ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users versus paper medical records as acknowledged by the increased security requirements for electronic medical records included in the Health Information and Accessibility Act and by recent large-scale breaches in confidential records reported by EMR users.

Concerns about security contribute to the resistance shown to their widespread adoption. Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.

Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records.
Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.

In contrast, EMRs can be continuously updated (within certain legal limitations - see below). The ability to exchange records between different EMR systems would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities but unfortunately this has been rater slow in coming as many of the major players prefer and continue to use proprietary systems as a way to prevent custoemrs from adopting newer or other competitors systesm.

As mentioned previously, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.