EMR vs. EHR – Is There a Difference? Electronic records are expected to make the medical records review faster and more efficient. This article highlights the difference between EMR and EHR.
Managed Outsource Solutions 8596 E. 101st Street, Suite H Tulsa, OK 74133
EMR vs. EHR – Is There a Difference? Medical records form the basis of injury cases and help identify the nature of the injury, and the damage it caused. Therefore the importance of medical record retrieval and medical records review cannot be overstated. This is the age of the electronic health record, which is expected to transform the way care is provided while also lending more legal value to the medical record. Many people use the terms EHR (electronic health record) and EMR (electronic medical record) interchangeably. But is there a difference between the two? Yes, there is a fine distinction between the two. According to the Office of the National Coordinator for Health Information Technology (ONC), the federal agency that is responsible for overseeing health IT certification, these are the descriptions for EMR, EHR and PHR (personal health record). The Difference EMRs are digital versions of the paper charts in clinics, clinician offices and hospitals. They contain notes and information collected by and for the clinicians in that office, clinic, or hospital and are typically provided by providers for diagnosis and treatment. These digital records are more valuable than paper records because with these providers can track data over time, identify patients for screenings and preventive visits, monitor patients, and improve the quality of healthcare. EHRs are more comprehensive than EMRs, they go beyond the standard clinical data collected in a provider’s office. They present a broader view of a patient’s care, and contain information from all the clinicians involved in a patient’s care. All authorized clinicians involved in a patient’s care can access the information contained in the EHR and provide timely services to the patient. EHRs enable information sharing with other healthcare providers such as laboratories and specialists. The EHR is available wherever the patient goes, whether to a specialist, nursing home, hospital or even across the country. Personal health record or PHR contain the same types of information as EHR, regarding diagnoses, medications, family medical histories, immunizations, and provider contact information. However, they are set up, accessed and managed by patients. The patients can use their PHR to maintain and manage their health information in a secure and confidential environment. PHRs contain information from a variety of sources including clinicians, home monitoring devices and the patients themselves. Two former ONC leaders Peter Garrett and Joshua Seidman PhD clarify that “The EMR is the legal record created in hospitals and ambulatory environments that is the source of
www.mosmedicalrecordreview.com
(800) 670 2809
data for the EHR. The EHR represents the ability to easily share medical information among stakeholders and to have a patient's information follow him or her through the various modalities of care engaged by that individual. Stakeholders are composed of patients/consumers, healthcare providers, employers, and/or payers/insurers, including the government.” You can clearly understand the difference between EMR and EHR if you take into consideration the term “medical” versus the term “health.” While the EMR provides a narrower view of the patient’s medical history, the EHR is a more comprehensive report of the patient’s overall health. Benefits of EHR and EMR Providers of medical record review for attorneys will agree that compared to traditional paper records, the information contained in the electronic health record is more accurate, current and clear. Electronic records offer many benefits such as: ➢
Since the information is timely, accurate and updated, medical errors are reduced and healthcare is improved.
➢
Complete information helps in more accurate diagnoses.
➢
Patient charts are more complete and clear.
➢
Since information can be shared, there is reduced duplicate testing which in turn saves time, money and hassle for patients and providers.
➢
Patient participation is more; therefore this ensures healthier lifestyles and more frequent use of preventive care.
Designed for the Patient EHRs are designed for the patient. They are expected to make healthcare more efficient and less costly. EHRs keep the patient aware of each detail regarding their treatment and this keeps them satisfied. They can access their medical charts from anywhere and provide this information to their families or new practitioners. Is There a Legal Difference? According to AHIMA (American Health Information Management Association), “the legal health record is the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization. An organization’s legal health record must explicitly identify the sources, medium, and location of the individually identifiable data that it includes. ... The documentation that comprises the legal health record may physically exist in separate and multiple paperbased or electronic systems.” Entities covered under HIPAA were requested to consider
www.mosmedicalrecordreview.com
(800) 670 2809
the components of EHR technology that generate patient health data, storage capacity and cost, and the ability of the EHR system to produce readable electronic and paper copies of the legal health record. The third edition of AHIMA’s health IT pocket glossary makes a clear distinction between EMR and EHR: Electronic medical record (EMR): An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians
and
staff within
a
single
healthcare
organization.
Electronic health record (EHR): An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization. Since neither definition speaks to the legal record, it can be concluded that either definition could contribute to this set of documents and information related to a provider’s treatment of a patient. When considered alongside AHIMA’s guidance on the legal medical record, that contains no mention of EMR and prefers EHR, the acronym EMR could be too constricted for the American healthcare industry that is aiming to establish a learning healthcare system.
www.mosmedicalrecordreview.com
(800) 670 2809