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INTRODUCTION

OBJECTIVES

Following completion of this chapter, the reader will be able to:

  • Explain the history of electronic medical record (EMR) development leading up to the current mandate for transitioning to an EMR.

  • Explain the concept of “meaningful use” in regards to EMR adoption.

  • Explain the difference between an electronic medical record and electronic health record.

  • Compare and contrast the benefits of point of care use of EMR versus workstations or documenting outside the patient visit.

  • Discuss the three primary considerations when considering software for the electronic medical record.

  • Analyze the relationship between an EMR system and evidence-based practice.

Author's Note

The terms electronic health record (EHR) and electronic medical record (EMR) are often used interchangeably, although they are different. While the EMR is used by clinicians and staff within one healthcare organization, the EHR conforms to nationally recognized interoperability standards and can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization. For purposes of this chapter, the term EMR will be used, but should be recognized to include EHR as well.

The implementation and use of electronic medical records (EMR) is 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 the healthcare professional 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 result of use of this technology is 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 across health systems, leading to better coordination of care. There are many integrated outcome programs. Physical therapists (PTs) need to be able to use quality measures to articulate the value they bring to the healthcare system, given that in the near future payment for services will depend on quality measure performance.1

  • 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 ...

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