An electronic medical record (EMR) is a digital record of patient information. Electronic medical records provide digital documentation of healthcare providers' interactions, such as office visits, telephone calls, and lab work. These records document a patient's medical history and are usually available to providers at the point of care.
Information recorded includes insurance information, patient demographics and treatment records. EMR systems also allow providers to enter progress notes and other notes regarding a patient's care. Authorized healthcare providers and patients can access the records virtually.
The software is developed by companies that offer a variety of experiences in building software products for multiple industries, including healthcare. EMR software can be customized to meet the needs of an individual medical practice or hospital and integrates with existing practice systems. EMR software is updated periodically to incorporate new features, add new data types to the database, and meet compliance and security standards.
Features of an EMR system may include using natural language processing (NLP) to detect anomalies in clinical notes. Natural language processing is a type of artificial intelligence that processes text and information, such as medical terms and abbreviations. Computerized medical records allow for more accurate medical billing because the software can detect and correct errors during the claim submission.
A key component of EMR software is an electronic health record (EHR). This feature allows for storing, organizing and accessing patient medical information. Medical staff members can access the EHR with permission during the healthcare process. Instant access allows for a more efficient workflow because there is no need to locate and process information manually.
The EHR is integrated with a related medical software package, such as screens in EMR software, which allows users to input information more intuitively. Users can view specific sections simultaneously and filter through different data points. The flow of information is more efficient because the user does not have to traverse through multiple screens.
Electronic medical records software can store, organize and access patient information. Because most EMR systems use cloud storage, healthcare providers can access patient records from any location. Healthcare information can be accessed via the internet using a mobile device or desktop computer.
The goals of most electronic medical records software are to provide a faster workflow, increase physician productivity and reduce medical errors. Electronic medical records software should also meet HIPAA compliance requirements, reduce the number of medical errors and have additional security features to protect patient data. Providers can use the software to enhance productivity and patient safety.
The efficiency of an EMR system depends on individual medical practices. Medical practices' choice of data entry method impacts the speed and efficiency of their EMR systems. In addition, the process of data entry used will impact privacy and security. Finally, the data storage structure in an EMR system may affect the speed and efficiency of workflow.
Multiple software options are available today, designed for different types of healthcare providers. Some Electronic medical records software packages are designed for small medical offices, while others can handle larger hospital settings.