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Electronic medical record systems lie at the center of any computerised health information system.

Without them other modern technologies such as decision support systems cannot be effectively integrated into routine clinical workflow. The paperless, interoperable, multi-provider, multi-specialty, multi-discipline computerised medical record, which has been a goal for many researchers, healthcare professionals, administrators and politicians for the past 20+ years, is however about to become reality in many western countries.

Terms used in the field include electronic medical record (EMR), electronic patient record (EPR), electronic health record (EHR), computer-based patient record (CPR) etc. These terms can be used interchangeably or generically but some specific differences have been identified. For example, an Electronic Patient Record has been defined as encapsulating a record of care provided by a single site, in contrast to an Electronic Health Record which provides a longitudinal record of a patients care carried out across different institutions and sectors. But such differentiations are not consistently observed. C. Peter Waegemann in his Medical Record Institute EHR Status Report provides, within a historical context, a summary of the different functions and visions implied by the various terms used to refer to EMRs.

The 2003 IOM Patient Safety Report describes an EMR as encompassing : 1. longitudinal collection of electronic health information for and about persons. 2. [immediate] electronic access to person- and population-level information by authorized users; 3. provision of knowledge and decision-support sysems [that enhance the quality, safety, and efficiency of patient care] and 4. support for efficient processes for health care delivery." [IOM, 2003, P4 (footnote)] The HIMSS EHR definitional model document [HIMSS, 2003] includes "a working definition of an EHR, attributes, key requirements to meet attributes, and measures or "evidence" to assess the degree to which essential requirements have been met once EHR is implemented".

The 1997 Institute of Medicine report: The Computer-Based Patient Record: An Essential Technology for Health Care, provides the following more extensive definition: "A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems)." [IOM, 1997] The HIMSS EHR definitional model document [HIMSS, 2003] includes "a working definition of an EHR, attributes, key requirements to meet attributes, and measures or "evidence" to assess the degree to which essential requirements have been met once EHR is implemented".

The US IOM report, Key Capabilities of an Electronic Health Record System [Tang, 2003], identified a set of 8 core care delivery functions that electronic health records systems should be capable of performing in order to promote greater safety, quality and efficiency in health care delivery: Health information and data. Result management. Electronic communication and connectivity Patient support. Administrative processes. Reporting.

Order management
Decision support.