Administrators of today’s medical practices are facing rapid changes in the management of patient health information as advances in technology occur and government initiatives influence the direction of healthcare information systems. Understanding the evolving terminology and concepts used to describe this vast array of technology is fast becoming a pivotal part of the needs of a medical practice. Here is a look at some of the key concepts.
A Document Management System (DMS) is an early form of a record management system. A DMD is a system used to track and store electronic documents or images of paper documents in a physician’s office. It does not generally assume the interconnectivity capabilities of an electronic medical records system, although more recent systems offer the option of an integrated platform. Examples include voice recognition software, a desktop database, or a template-driven document production system.
An Electronic Medical Record (EMR) offers increasing sophistication over a document management system. An EMR is the creation of a medical document within a physician’s office with the added capability of the import of information from a variety of external sources such as laboratories, radiology centers and pharmacies. Often, this record can also be exported to offices outside the physician’s practice, including the patient, pharmacist, referring physician or specialist. An electronic medical record usually offers full interoperability within an enterprise.
An Electronic Health Record (EHR) is a more universal health care record than an EMR and it’s management is not centralized by one physician, but rather contains a longitudinal record of a patient’s health from multiple health care offices. For example, the content of an EHR may come from a primary care physician, a bone density practitioner, a laboratory, a pharmacy and an insurance carrier. Each of these sources of information can both receive and give new information. Since the information flow of an EHR is “bi-directional” (giving and receiving) and the content includes the total experiences of the patient, it is distinguishable from an EMR. The EHR also supports the collection of data for uses “other than clinical care, such as billing, quality management, outcomes reporting, and public health surveillance and reporting”. (HIMSS, 2002)
A Continuity of Care Record (CCR) is an electronic health record that meets certain standards of portability and data exchange. ASTM International, the Massachusetts Medical Society, HIMSS, the American Academy of Family Physicians, the American Academy of Pediatrics and health informatics vendors jointly developed the standards describing a CCR. The goal was to create a CCR that will enable each healthcare provider to access and transport historical health information in order to support the safety, quality, and continuity of patient care. The CCR may be used as a vehicle to exchange clinical information among providers, institutions, or other entities. Because the CCR is an XML standard document, it will be both machine and human readable, and the data content may be displayed or printed in a variety of formats, including by web browser, PDF reader, and word processor.
Benefits of the CCR
The CCR is expected to have a significant impact on the quality of care by reducing medical errors and limiting costs:
- A healthcare provider will not have to search for or guess about a patient’s allergies, medications, or current and recent past treatments.
- A healthcare provider will be informed about the patient’s most recent healthcare assessment and services.
- Patient demographic information can be quickly and easily verified.
- A patient’s insurance status will be more easily identified and established.
- Costs associated with the patient’s care may be reduced, such as avoiding redundant tests.
- The effort required to update the patient’s essential information will be minimized.