The Emergence of the Electronic Medical Record
Historically the medical history of a patient was stored as a paper-based document at the site of the medical appointment. A paper-based system was used as that was the availability of the technology, it was easy to use, and it was the approach most widely implemented (Bates, Ebell, Gotlieb, Zapp, & Mullins, 2003). These paper records, though easy to use, had their own disadvantages: the documents were not easily accessible from other sites, the information was often illegible, and they could only be used by a single person at a time (Bates, Ebell, Gotlieb, Zapp, & Mullins, 2003). Therefore, when the patient received any medical attention at any other site, their record was disconnected and incomplete, unless the required document was transferred to the patient’s primary medical practitioner’s location either through courier, mail or fax.
Today most medical institutions now employ an electronic format for storing a patient’s information. This document, specific to the medical institution providing the care, is referred to as an electronic medical record (EMR). The EMR records the patient’s demographics, medical and drug history, and results from various test sources. When regarding health information technology (HIT) the EMR is recognized as a valuable tool for improving the quality, safety and the efficiency in health care systems (Jha, Doolan, Grandt, Scott, & Bates, 2008).
However, as was the case with the paper-based solution, the electronic medical story of the patient is spread among many different institutions where they may receive care: emergency rooms, specialized medical facilities such as cancer clinics, specialist practitioners such as rheumatologists, etc. When consolidating all the medical information for a single patient an electronic health record (EHR) emerges that contains a more complete story of the patient as they interact with the medical system.
Patents for EMR systems were starting to be registered in the early 1990’s (Evans, 1999) (Myers & Culp, 1998) showing that they were being investigated seriously as a replacement for the paper-based solutions. Since their inception, the uptake of the EMR has been ever increasing. EMR adoption from early 2000 to 2010 saw an increase from 16% to 52% (Kokkonen et al., 2013). With the American government providing incentives and enacting legislation, the saturation of the EMR has increased further. After the introduction of the Health Information Technology for Economic and Clinical Health (HITECH) Act, EMR adoption in non-federal hospitals, in emergency departments and by hospital-based physicians has improved to between 78% and 94% (Mennemeyer, Menachemi, Rahurkar & Ford, 2016).
With this increasing use of the EMR there are many vendors that are developing their own variation of an EMR system. Each vendor has chosen to implement their system so that it provides the information in the way that they believe their client would want it displayed, managed, and interacted with. Underneath the operations of the system, all the information that is entered into the system is stored in some proprietary format.