The implementation and use of electronic medical records (EMRs) is now one of the highest priorities for healthcare providers, organizations, and government agencies in the United States. An EMR can provide many benefits for providers and their patients, and can improve care by enabling functions that paper medical records cannot deliver:
- Complete and accurate information. An EMR allows healthcare professionals to have the information they need in a timely fashion in order to provide the best possible care, at the best possible time. The ability to access the patient's complete health history before beginning the evaluation and treatment processes affords additional support for the provider's clinical decision-making process as well as facilitating the patient's involvement in their own healthcare. Use of an EMR has the impact of bringing an individual's complete health information picture into the process of getting appropriate care earlier rather than later. The use of this technology results in better healthcare decision making, and more coordinated care.
- Better access to information. EMRs facilitate greater access to the information healthcare providers need to support high-quality and efficient care and improve the health outcomes of their patients. EMRs also allow information to be shared more easily among physician, therapist, and other healthcare provider offices, hospitals, and health systems, leading to better coordination of care.
- Patient empowerment. Use of EMRs empowers individuals to take a more active role in their health and in the health of others for whom they have responsibility. Patients can receive electronic copies of their medical records and share their health information securely over the Internet with whomever they choose. EMRs can support better follow-up information for patients—for example, after a clinical visit or hospital stay, instructions and information for the patient can be effortlessly provided, and reminders for other follow-up care can be sent easily or even automatically to the patient.
Currently, a majority of healthcare providers still use medical record systems based on paper, yet this is generally the most inefficient and time-consuming manner in which to document, especially if the required or desired elements are to be documented correctly. With the ongoing political and economic pressure to incorporate health information technology into practice, it is essential for physical therapists, and other healthcare providers, to understand the benefits and barriers to adoption of electronic documentation, the potential effects of introducing point-of-care (PoC) documentation into the therapist–patient relationship, and key points to consider prior to the lease or purchase of a system in order to effectively prepare for the successful transition to an EMR.
Health Information Technology (HIT) is changing rapidly in the United States. The goal at the federal level is to have EMR systems in use across the country, in all provider settings, by 2014. A 2008 study published in the New England Journal of Medicine found that only 4% of doctors nationwide used a fully functioning EMR system, while only and additional 13% said they had a basic system....