Electronic medical records
An electronic medical record (commonly abbreviated EMR) is a generic term used to describe computer-based patient medical records. The term has become expanded to include systems which keep track of other relevant medical information.
An EMR facilitates
- easy look up of patient data by doctors and nurses
- easy claims processing by insurance companies
- easy transfer of information when a person changes medical facilities
- easy access to the medical history of a patient
As a consequence, an EMR also permits easy invasion of medical privacy.
Medical informatics
Electronic records fall under the purview of medical informatics, a combination of computation and computer science and medical record keeping. As a field, Medical informatics has transcended its beginnings as a bioengineering subspecialty.
History
Medical informatics began in the 1950s with the rise of useable computation devices, computers.
Early names for medical informatics included medical computing, medical computer science, computer medicine, medical electronic data processing, medical automatic data processing, medical information processing, medical information science, medical software engineering and medical computer technology.
The earliest use of computation for medicine was for dental projects in the 1950's at the National Bureau of Standards by Robert Ledley.
The next step in the mid 1950s were the development of expert systems such as MYCIN and INTERNEST-I. In 1965, the National Libray of Medicine started to use MEDLINE and MEDLARS. At this time, Neil Pappalardo, Curtis Marble, and Robert Greenes developed MUMPS (Massachussetts General Hospital Utility Multi-Programming System) in Octo Barnett's Laboratory of Computer Science at Massachussetts General Hospital in Boston. In the 1970s and 1980s it was the most commonly used programming language for clinical applications. The MUMPS operating system was used to support MUMPS language specifications. As of 2004, a descendent of this system is being used in the United States Department of Defense hospital system.
In the United States in 1996, HIPAA regulations concerning privacy and medical record transmission created the impetus for large numbers of physicians to move towards using EMR software, primarily for the purpose of secure medical billing.
Standards
Though there are few standards in modern day EMR systems, there are a number of standards and practices bodies which have drafted interchange formats which are in use.
- HL7 - This format has been in use for interchange between hospital and physician record systems.
- ANSI X12 (EDI) - Used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information.
