EMRs vs. Paper Records
An Electronic Medical Record Should Still be a Medical Record
The casual and blanket use of a fairly specific term to describe any software tool used in patient care overlooks the functionality promised by true electronic medical records. One of the easiest ways to illustrate the differences is to first visualize a traditional paper chart for comparison purposes.
| Paper Medical Records | Electronic Medical Records |
|---|---|
| A paper patient record is identified by name, some kind of medical record number, and other identifiers that make it easier to find in the filing system. | An EMR provides distinct identifying information for each patient, and identifiers to locate the digital record among any number of other records. |
| Paper charts typically contain demographic and insurance information, along with a list of medical problems, medications, and allergies. These must be readily updated and should stay current and accurate. | An EMR maintains this information, and shares any updated information wherever it is needed. When updated insurance information is provided, that information is automatically passed to billing so that the information is consistent and current, without the need for duplicate data entry. In addition, clinical information such as problem lists and medication lists are readily updated without duplicate data entry, so that changing medications within the charting application automatically updates the patient's medication list. |
| A paper medical record contains office or progress notes in chronological sequence. These are "browsed" by literally flipping through pages, until the desired entry is located. Progress notes in a traditional paper record might be produced by dictation/transcription, free handwriting, or form completion. |
An EMR stores progress notes and provides quick access by date of visit, provider, or other search criteria and the ability to browse by diagnosis and prescription. A full function EMR automatically creates the progress notes as the visit is produced. |
| Laboratory and radiology reports, as well as correspondence, are filed in more or less chronological order. Access to specific entries is no more efficient than it is with progress notes. | An EMR stores reports in any number of ways to provide rapid access and quick reference, such as scanned images, direct lab result posting, even on-line lab information applications. Using common demographic and identifying information, access to specific lab results or other patient reports is highly efficient and useable. |
| If a paper chart is filed correctly in the medical records system, a staff member must go to the stacks of charts and, using some quick identifier code, locate the correct last name. The first name is located and confirmed, then the chart is "pulled", but not before a placeholder is inserted, in order to 1) make re-filing easier and 2) record where the chart is headed. The issues surrounding finding a chart that is "out" somewhere, or has been incorrectly filed, are easily imagined. | An electronic chart is never lost, out, or misfiled. It is always exactly where it should be, even if you aren't. That is to say that an electronic record may be accessed from any point in a healthcare facility that has access to medical records. |
In a paper chart system, a healthcare provider typically writes a paper prescription for the patient to take to a pharmacy. There are often one or more added steps, such as:
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Electronic medical records with robust clinical decision support offer reference information regarding optimal treatment, such as treatment guidelines or "best practice" standards. An EMR with prescription writing capability performs the allergy and drug interaction checking, or at least provides a quick reference for manually checking, when the desired drug is selected. In addition, an EMR with electronic prescribing capability can send the prescription to a designated pharmacy directly, while at the same time documenting the prescribing process and updating the patient's medication record. |