ABSTRACT
Over the past 30 years, the definition of an electronic medical record (EMR), also called a computer-based patient record (CPR or CbPR), has evolved considerably, in parallel with changes that have swept through the healthcare industry itself. The Computer-Based Patient Record Institute now offers these definitions that differentiate the record itself from the system for maintaining it:
Because medical information is stored in many places, by many entities, the definition naturally depends on the stakeholder’s perspective. To a physician, it would be an electronic replacement for the manila folder he or she uses to gather and store office notes, lab results, and external reports pertaining to a particular patient over an extended period. In the hospital, the paper medical record has traditionally been admission-centered, but the electronic record presents an opportunity to move beyond
that to create a more longitudinal, patient-focused database. To an insurance plan, it might involve primarily enrollment information, benefits descriptions, and claims history. To an enterprise attempting to coalesce several of these entities into one, thereby forming an
integrated delivery system (IDS)
, the creation of an integrated system of electronic records has emerged as a key strategic goal without which successful integration is unlikely.
