Electronic Medical Record (EMR)

What is an electronic medical record?

An EMR replaces paper charts inside one clinic, hospital or medical group. It stores diagnoses, medications, allergies, test results and visit notes, and it helps staff track when patients are due for screenings or follow-up care.

The term dates from early generations of clinical software, when systems were built mainly for internal documentation and billing. Data in a classic EMR tends to stay inside the organization unless someone prints, faxes or exports it.

EMR vs EHR

Federal health IT guidance draws a distinction between the two terms, even though vendors and clinicians often use them interchangeably:

• Scope: an EMR covers care delivered within one organization, while an electronic health record (EHR) is meant to give a broader view of a patient's health across care settings.
• Sharing: an EHR is built to move information to other providers, laboratories, pharmacies, registries and patients; a classic EMR was not.
• Regulation: federal law and CMS programs use the term EHR, as in Certified EHR Technology (CEHRT) and the EHR Incentive Programs created by the HITECH Act.

Why the EMR label matters

Most systems sold to U.S. hospitals and physician practices today are certified under the ONC Health IT Certification Program and support standards-based exchange, so they meet the functional idea of an EHR even when a vendor or buyer calls them an EMR.

The label still causes confusion when reading regulations, contracts and market data:

• Regulatory documents, such as Medicare Promoting Interoperability rules, refer to EHRs and certified health IT, not EMRs.
• Procurement records, job postings and vendor marketing mix the two terms, so research that counts only one label will undercount systems.
• A product marketed as an EMR may or may not appear in the Certified Health IT Product List (CHPL); certification status, not the name, decides whether it satisfies CMS requirements.
• Settings that were not eligible for HITECH incentive payments, such as many behavioral health and long-term care providers, adopted EHRs more slowly, and their systems are less likely to be certified.