Transcript Level 1: Automated Medical Record

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Five Levels of
Computerization
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1
•EMR: Electronic Medical Record
•EPR: Electronic Patient Record
•CPR: Computer-based Patient
Record
•EHR: Electronic Health Record
•Automated Medical Record
•Computerized Medical Record
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Level 5: Electronic Health Record
(longitudinal, comprehensive)
Level 4: Electronic Patient Record
(spans across organization)
Level 3: Electronic Medical Record
(Active tool, organization level)
Level 2: Computerized Medical Record
(document imaging)
Level 1: Automated Medical Record
(clinical info systems)
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Level 1:Automated Medical
Record
• the health care organization still
depends on paper-based medical
record system, although
• nearly half of the patient
information may be computer
generated and stored as computer
printouts within the medical
record.
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• The health care organization may
automate certain functions such as
patient registration, scheduling, results
(radiology and laboratory) reporting,
and dictation.
However,
• at this level the paper- based medical
record system remains the primary
source for entering and retrieving the
patient’s clinical information,
and
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• the problems inherent in using
paper records (availability,
legibility, completeness) still
exist.
• Automated medical records
are managed by organizations.
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Level 2: Computerized Medical
Record.
• The next level 2, involves digitizing
the patient’s medical record through
the use of a document imaging
system.
• Much of the patient’s clinical
information is scanned into the
medical record and stored
electronically as optical images.
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• Document imaging systems
may be used by organizations
to address accessibility and
retrieval concerns and space
and storage issues associated
with paper medical records.
However
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• In other words, the computerized
medical record has essentially
the same structure as the paperbased medical record.
• Like the automated medical
record, the computerized
medical record is maintained by
the organization.
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• Many health care organizations
opt not to use document
imaging systems. They see
them as
• a costly storage medium and
as an unnecessary step in
getting to the next level, the
electronic medical record.
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Level 3: Electronic Medical
Record.
Up until this point the medical record has
served as a passive storage device.
• It is at Level 3, the electronic medical
record (EMR), where we begin to
see the patient record as an active
tool that can provide the clinician
with decision- support capabilities
and access to knowledge resources,
reminders, and alerts.
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• Although still used and maintained at
the organizational level, the EMR
provides the clinician with access to
decision- support capabilities and
other aids.
For example, the EMR may alter the clinician to
the fact that the patient is allergic to certain
medications or that two medications should not
be taken in combination with each other. It may
trigger a reminder that the patient is due
for a health maintenance test such as a
mammography or cholesterol test .
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Level 4: Electronic Patient Record
Whereas the electronic medical record
contains only the patient information that is
maintained by a single organization.
• The electronic patient record
includes all health care-related
information concerning the
patient---gathered across two or
more organizations.
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• An electronic patient record brings
together in a central database all
clinical information available on a
patient.
For example if a primary care physician saw a
patient in the physician’s office, admitted the
patient to a hospital, and then discharged the
patient to a rehabilitation facility, all relevant
information concerning the patient would be
available to clinicians involved in the
patient’s care across these three settings. 15
• This level of computerization requires
(1) a system of identifying all patient
information available,
(2) a way to combine information from
multiple facilities,
(3) a common terminology and structure,
and
(4) a consensus on security.
The electronic patient record system is
comparable in its scope and functions to
the CPR.
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Level 5: Electronic Health Record
• The electronic health (EHR) is
broader in scope than the
electronic patient record and
• includes wellness information
and
• other information not routinely
maintained by health care
organizations.
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• Wellness information might include
data on the individual’s smoking
habits, nutrition, level of exercise,
dental health and alcohol use.
• The patient is at the center and all
information related to the individual’s
health and wellness is brought
together as needed in managing the
patient’s care and treatment more
effectively.
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• The EHR is a longitudinal
record and ultimately
would encompass as
person’s relevant health
information from before
birth to death.#
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EHR (longitudinal, comprehensive)
EPR/CPR (spans across organization)
EMR (Active tool, organization level)
Computerized MR (document imaging)
Automated MR (clinical info systems)
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References:
• Wager Karen A, Wickham Lee Frances, Glaser P
John.Managing Health Care Information System.
USA, Jossey Boss 2005.
• Dana C.mc way, JD. Todays health information
management, an integrated approach, Thomas
Delmar learning, 2008.
• Englebardt Sheila P, Nelson Romona. Health Care
Informatics. Mosby, 2002.
• Jordan Theresa J. Understanding medical
information. McGraw-Hill, 2002.
• Abdelhak Mervat, Grostick Sara, Hanken Maryalic,
Jacobs Ellen. Health Information: Management of a
Strategic Resource. Second edition. W.B. Saunders
Company. 2001.
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