Nursing Informatics

EMR vs. EHR /Reading & Sharing Nursing Informatics

HIMSS Analytics, a not-for-profit subsidiary of the Healthcare Information and Management Systems Society (HIMSS) outlined the differences between the terms electronic medical record and electronic health record, defining the electronic medical record (EMR) as the “legal record created in hospitals and ambulatory environments that is the source of data for the EHR.” The EMR typically referred to a single encounter with no, or very limited, ability to carry information from one visit to another within a care delivery system. That situation has changed so that it is possible to bring information forward from prior visits within the organization or delivery system.

Basic EMR components:

  • clinical messaging and email
  • results reporting
  • data repository
  • decision support
  • clinical documentation
  • order entry

In 2008 the National Alliance for Health Information Technology define electronic health record (EHR) as “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by aythorized clinicians and staff across more than one health care organization.”

  • The primary distinction between the EMR and EHR was the ability to exchange information outside of a single healthcare delivery system.
  • The EMR is considered a building block in the creation of the EHR.

 

Attributes of EHR:

  • provides secure, reliable real-time access to client health record information where and when it is needed to support care
  • records and manages episodic and longitudinal EHR information
  • functions as clinicians’ primary information resources during the provision fo client care
  • assists with the work of planning and delivery of evidence-based care to individual and groups of clients
  • captures data used for continuous quality improvement, utilization review, risk management, resource planning, and performance management
  • provides longitudinal, appropriately masked information to support clinical research, public health reporting, and population health initiatives
  • supports clinical trials and evidence-based research

 

A primary purpose of the National wide Health Information Network (NsHIN) is to ensure secure Internet exchange of information through standards, policies, and services. NwHIN is funded by the Office of the National Coordinator for Health Information Technology (ONC). The primary goal is to assist health care providers to move from a system of paper medical records to a secure electronic health record that can be easily accessed by various healthcare providers and utilized to evaluate the quality of care.

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