Digital Health 101February 6, 2022

EMR Systems Defined

Capable Health Team


According to a survey from the Stanford School of Medicine, 6 in 10 primary-care physicians agree that electronic medical records (EMR) systems have led to improved patient care, both in general and within their practice, but 43 percent also want improved predictive analytics to support disease diagnosis, prevention, and population health management in the next decade.

EMR Systems Meaning

EMR systems are defined as an individual electronic record of health-related information that can be created, gathered, managed, and consulted by authorized clinicians and staff within healthcare organizations. These systems improve the quality of patient care and safety and provide several benefits to doctors and healthcare organizations. 

What are the key functions of EMR systems?

For a better understanding of what EMR systems are and their meaning, it’s important to highlight the basic functions for safety, quality, and efficient care issued by the National Academy of Medicine for healthcare organizations that implement EMRs. 

These eight requirements allow providers to easily compare the systems currently available and help vendors build systems that meet provider expectations. The requirements include:

  1. Having immediate access to health information, including patient diagnosis, allergies, lab test results, and medication to help providers make sound clinical decisions in good time.

  2. Providing easy access to a patient’s new and past test results for all providers participating in the treatment process in order to increase safety and effective care.

  3. Entering and storing orders for prescriptions, tests, and other services to enhance legibility and reduce duplication.

  4. Using computerized decision-support systems such as reminders, prompts, and alerts to improve compliance with best clinical practices, identify possible drug interactions, and facilitate treatment.

  5. Enabling efficient, secure, and readily accessible communication between providers and patients to improve the continuity of care and reduce the frequency of adverse events.

  6. Tools that give patients access to their health records and provide interactive patient education to help them carry out home-monitoring and self-testing when necessary.

  7. Computerized administrative tools such as scheduling systems, to provide more timely service to patients.

  8. Electronic data storage with uniform data standards to enable healthcare organizations respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance.

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Types of EMR Systems

Digital innovations in the healthcare industry have given rise to high-quality EMR systems that can be readily accessed by providers. Today, a wide range of EMR software options are available to cater to the individual needs and abilities of different healthcare organizations, and they are broadly grouped into several categories based on their features.

1. Cloud-Based Systems

Most web-based systems are hosted in a secure data center, and cloud-based EMRs allow access to the system from any device. Security is provided upon payment of the leasing fee, and this means that the system is protected every time it’s accessed. Since cloud-based systems require less hardware to operate, there’s no need to purchase or maintain a server, and involves less concern for data backup or recovery.

2. Server-Based Systems

Server-based EMR systems offer more advantages for on-site data hosting. In this case, the healthcare practice typically owns the software and the licenses, so it can be installed on many devices without external support. Access to the system can be granted at any time through remote connections, and it also increases speed and performance for all systems, since they are located on-site.

3. ONC-Certified Systems

ONC-Certified EMR systems cover the requirements set by the Office of the National Coordinator for Health Information Technology (ONC). They focus on effective use and storage of sensitive patient data, and are tested by ONC-authorized bodies to ensure that the systems meet the criteria for the meaningful use of health information. The criteria includes patient portal access, quality reporting methods, a place to create care plans, and more.

4. Medical Billing Systems

Some software integrates with EMRs to function as a complete administrative system, primarily created to handle medical billing. Patient statements and insurance claims can be managed more easily with these systems, as they provide a way to automate ordinarily onerous billing tasks, such as verifying insurance, processing claims and payments, as well as following up on denied insurance claims.

5. Behavioral/Mental Health Systems

Mental health EMR systems, also known as behavioral systems, allow therapists, psychologists and other related professionals to manage clinical, administrative and operational processes. For instance, tracking and accessing patient medical history can be a laborious task for a therapist or mental health provider, but advanced data management features on behavioral/mental health EMR systems have made accessing this information a seamless and efficient process. This is one out of a wide range of features on these systems that are designed specifically to meet the needs of professionals in this field.

6. Mac Systems

This includes EMR software specifically compatible with all Apple devices. Mac EMR systems are further grouped into two: the Mac-native options, which are exclusively designed for the Mac operating system, and cloud or web-based options that are optimized for any Apple device with internet access.

How to Use EMR Systems

Beyond defining the meaning of EMR systems and their benefits, one of the key features is the ability to manage interactions between provider and patient. However, making the transition from a physical system to EMR system may pose some challenges for providers. 

For providers, the following tips can help improve the quality of care provided and increase competence while using EMR systems.

  • Keep care patient-centered, rather than system-centered. Interacting with a patient and entering their clinical information into an EMR system both require focus, but it’s important to be aware of how much time is taken up by records.

  • While discussing sensitive issues with a new patient, let them know that they have your full and undivided attention by maintaining eye contact and making sure hands are away from the computer.

  • Keep interaction with the patient going while entering data into their record. When discussing data, point to the screen to show results and encourage questions and participation.

  • Review the list of concerns, problems, and previous notes before entering the examination room to improve efficiency and optimize patient satisfaction. Separating routine data entry will allow more time to interact with the patient.

  • Allow the patient to drive the flow of information while directing content to clinically relevant topics. 

  • Many EMR systems include documentation templates or allow users to create their own. Making use of these templates can significantly reduce the time required to chart for patient visits, findings, and referrals.

  • With increased familiarity with the EMR system, make a concerted effort to enhance screen-scanning speed, browsing speed and accuracy, and learn to use the decision support effectively.

Barriers to Use for EMR Systems

Using EMR systems effectively means encompassing a quality and coherent care process, automated guidelines, and an improved treatment process. But there are some potential challenges to consider before implementation or when making the switch to a new system.

Interoperability Challenges 

Interoperability refers to the smooth transfer of patient data between systems. The process of data transfer is often challenging and can make it difficult for a primary care provider to refer a patient to a specialist. This is one of the major drawbacks of many EMR systems, but as more improvements are made in this field, and standards like FHIR are implemented, it is likely that interoperability will allow seamless data transfer between providers using EMR software.

Security

Many providers looking to adopt EMR systems are worried about the security of clinical data stored online. Compliance laws have brought safer platforms for recording and storing patient information, but before acquiring an EMR software it is important to take note of the technologies and policies put in place to ensure the safety of personal data.

User Adoption

The last decade has been marked by widespread adoption of EMR systems by healthcare organizations, but training remains essential to facilitate its implementation in hospitals and clinics. Clearly communicating the meaning of EMR systems and benefits to healthcare personnel who are less familiar with functionality, can help increase the benefits of EMR systems.

Downtime

In some cases, there may be an unexpected downtime on an EMR system due to maintenance or internet outage, especially with cloud-based systems. This poses a risk to patient safety and can result in loss or compromised data. It’s important to have processes in place that allow staff to provide adequate care and reduce the likelihood of similar issues to occur in the future.

Familiarizing yourself with EMR systems comes with its own challenges, but providers can benefit from structured guidance. 

Capable Health is a purpose-built developer platform to build best-in-class consumer health apps, the first API-driven platform dedicated to powering patient onboarding and engagement. Capable takes care of signup, onboarding, care plans, goal tracking, content delivery, secure messaging—the API middleware powering modern patient-facing healthcare experiences. At Capable Health, we’re helping healthcare organizations build best-in-class consumer health software and offering EMR system support for providers. 

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