Electronic Medical Records: The Future is Here

Some physicians have already incorporated alectronic medical records (EMRs) into their practices with success. Standardized enhancements to EMRs are on the horizon, with the goal of improved patient care.

Current efforts will reap eventual rewards

Steps toward EMR standardization are in process on a national level. Notably, the federal government has begun to address this pressing need. Department of Health and Human Services (HHS) initiatives include a standard EMR model and a common clinical medical vocabulary for EMRs. Licensed from the College of American Pathologists, the vocabulary will be available at no cost to users in the United States and will be accessible through the United States National Library of Medicine in 2004 (www.nlm.nih.gov).

In addition, a new Department of Defense EMR system will serve more than eight million patients whose care is administered by 12,000 military physicians. This effort, already underway, will take about five years to fully implement.

Adopting a standard EMR model and vocabulary will make it possible to ensure complete, up-to-date medical records. And the transfer of EMRs among clinics, hospitals and physicians has the potential to provide real-time information toward better patient care – an important plus from a risk management perspective.

Still, ongoing issues surround the use of EMRs. For instance, administrative challenges include:

• Confirming that all parties who access the EMR are using the most current patient information to determine a patient’s treatment plan.
• Addressing record ownership and sign-off procedures.
• Determining how and by whom information is selected, added
  and stored.

The bottom line is that development of EMRs is constantly evolving. Common models and vocabularies should make EMRs more user-friendly. For now, physicians should select EMRs developed with physician input and with keen consideration for the timely, quality care of patients and reduced administrative hassles for themselves and their practices.