What is an EMR? Health leaders come up with a definition

The IOM seeks to spark consensus on a standard, industrywide definition of an electronic medical record.

By Tyler Chin, amednews staff. Sept. 8, 2003.

The Institute of Medicine has identified a set of eight core functions that an electronic medical records software system should have in an attempt to develop consensus on a standard, industrywide definition of an EMR.

To date, the term has been defined many ways, making it difficult for physicians' offices and health care organizations to adopt or buy systems that can operate with each other, said Paul Tang, MD, chair of the IOM's Committee on Data Standards for Patient Safety.

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The IOM has forwarded its model EMR definition, commissioned by the Dept. of Health and Human Services, to Health Level Seven. The Ann Arbor, Mich.-based health care standards organization is working to develop the technical standards for each core functionality the IOM recommended that an EMR should have.

Having a common understanding of what an EMR is will make it easier for physicians to buy and evaluate systems, said Dr. Tang, who also is an internist and chief medical officer at the Palo Alto (Calif.) Medical Foundation, a 400-doctor multispecialty group practice.

A model EMR will help vendors build systems that meet the expectations of physicians and provider organizations, Dr. Tang said.

It also could accelerate an emerging trend by health insurers and employers offering physicians pay-for-performance incentives. In turn, that would encourage doctors -- and hospitals -- to adopt EMRs to realize and track quality measures, Dr. Tang said.

These are the core functions an EMR system should have, according to the IOM:

Health information and data: Immediate access to key information that would improve the ability of clinicians to make sound decisions in a timely manner. Those data include patients' diagnoses, allergies and laboratory test results.

Results management: Quick access of new and past test results by all clinicians involved in treating a patient.

Order management: Computerized entry and storage of data on all medications, tests and other services.

Decision support: Electronic alerts and reminders to improve compliance with best practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.

Electronic communication and connectivity: Secure and readily accessible communication among clinicians and patients.

Patient support: Tools offering patients access to their medical records, interactive education and the ability to do home monitoring and self-testing.

Administrative processes: Tools, including scheduling systems, that improve administrative efficiencies and patient service.

Reporting: Electronic data storage that uses uniform data standards to enable physician offices and health care organizations to comply with federal, state and private reporting requirements in a timely manner.