ELECTRONIC RECORDS - DEFINITION

Transcription

1 ELECTRONIC RECORDS - DEFINITION Today, in the health care domain there are many terms to describe Electronic Records: Computer-based Patient Record (CPR), Electronic Patient Record (EPR), Electronic Medical Record (EMR), Electronic Health Record (EHR), Continuity of Care Record (CCR), Personal Health Record (PHR), Virtual Health Record (VHR), Virtual Patient Record (VPR), Patient centered Record, and OpenEHR. Although it seems that these terms are synonymous, the following descriptions show how similar or different they are. The Institute of Medicine (IOM) described that the patient record or medical record is a complete and accurate source of a single patient s information traditionally documented on paper by medical practitioners during a period of care (Abdelhak, Grostick, Hanken, & Jacobs, 2007). From the Healthcare Information and Management Systems Society s (HIMSS) perceptive, EMR is a legal record documented in hospital and ambulatory care. It can be a foundation for the EHR. Based on this view, the HIMSS developed an eight-stage adoption model for the EMR, which is known as EMRAM (Figure 1). The EMRAM scores hospitals in the HIMSS Analytics database on their progress in completing the 8 stages to create a paperless patient record environment (Decman, 2011). The patient record in electronic format is defined as the EPR (Leiner, Gaus, Wagner, Haux, & Knaup-Gregori, 2003; Tan, 2005). In addition, both the CPR and EPR

2 also include alerts, reminders, and clinical decision support systems (Tan, 2005). In spite of this definition, it can be observed that there is a difference between the two terms CPR and EPR. The former is a system at the health care organization level while the latter is considered as an enterprise-wide system (Tan, 2005). By contrast, Hebda et al. (2005) believe that the CPR is a lifetime record that embraces all information of a single patient from all specialists whereas the EPR covers all information in the current episode of care. Normally, The CCR is a health-provider-oriented record included patient information, diagnoses, recent procedures, allergies, medications, and future treatment plans. Generally, the CCR is considered as a part of the EHR. The PHR is define as an individual record. In an internet-based record system, the patients can have access to his/her personal record to store and update personal medical information and schedule appointments or make inquiries to the health-care provider (Hamilton, 2011). The EHR is known as a comprehensive lifetime record from birth to death comprising all individual information related to the health status that is generated from multiple sources (Maki & Petterson, 2008; Tan, 2005). Decman (2011) expressed that the EHR is sum of the EMR and data exchange capability. Sometimes EHR is used as a general term for all types of electronic record (Hebda et al., 2005). Furthermore, OpenEHR is a form of the EHR to provide the ability of sharing data. It can be considered as an open standard to manage and exchange lifetime data through the EHR. The OpenEHR works based on common standards such as CEN TC251, ISO TC215, and HL7 (Hovenga et al.,

3 2010). In addition, The VHR, the VPR, and Patient centered record are commonly used interchangeable with the EHR. Waegemann (1996; cited in Wager, Lee, & Glaser, 2005) provided a detailed description of the terms that are used as electronic records through organizing them into five levels, which are as follows: - Level 1: Automated Medical Record; at this level some of the patient information may be gathered, organized, stored, and retrieved by computer but medical record still relies on paper. - Level 2: Computerized Medical Record; all or some parts of the medical record is scanned and saved on electronic devices such as, document imaging system. - Level 3: Electronic Medical Record; the EMR includes the patient information that is provided by a single health care organization. That is, the computerization of patient information is at the organizational level. What is more, EMR is used as an active tool for managing patient care that supports clinician to make clinical decisions and access to knowledge resources, reminders, and alerts. - Level 4: Electronic Patient Record; the EPR contains all health care patient information delivered across numerous health care organizations. From this view, the EPR is comparable to the CPR. The sharing of patient information across an organization starts from this level.

4 - Level 5: Electronic Health Record; the EHR is a longitudinal record from before birth to death. It embraces all the relevant health information of a particular individual. It seems that there is no common agreement on the differences of the abovementioned terms; however, the terms may be utilized based on the contents and implications of the electronic records.

5 Figure 1: The eight stages of HIMSS Analytics EMRAM ( )

6 References Abdelhak, M., Grostick, S., Hanken, M. A., & Jacobs, E. (2007). Health Information Management of a Strategic Resource (3rd ed.). Philadelphia: Saunders, Elsevier. Decman, M. (2011). Electronic health records management and preservation: The case of Slovenia. Paper presented at the 11th European Conference on egovernment, Ljubljana, Slovenia, Leiner, F., Gaus, W., Wagner, G., Haux, R., & Knaup-Gregori, P. (2003). Medical data management: a practical guide. New York: Springer-verlag. Hamilton, B. J. (2011). Electronic health records. New York: McGraw-Hill. Hebda, T., Czar, P., & Mascara, C. (2005). Handbook of Informatics for Nurses & Health Care Professionals (3rd ed.). New Jersey: Pearson Education Inc. Hovenga, E. J. S., Kidd, M. R., Garde, S., & Hullin-Lucay-Cossio, C. (Eds.). (2010). Health informatics: An overview. Amesterdam: IOS Press BV. Maki, S. E., & Petterson, B. (2008). Using the Electronic Health Record. Canada: Thomson Delmar. Tan, J. (2005). E-Health Care Information Systems: An introduction for Students and Professionals. San Francisco: Jossey_Bass. Wager, K. A., Lee, F. W., & Glaser, J. P. (2005). Managing health care information system: A practical approach for health care executives. USA: Josset-Bass.