EMR Guideline Page 9 of 12
EMR systems allow multiple providers to simultaneously enter data during a patient
encounter. This saves time tracking down and waiting to document in the hard chart.
The EMR is more readily searched than the hard chart, which often existed in multiple
volumes. The EMR is typically indexed by type of record, author, and date.
EMRs integrate different types of information that at one time were maintained in
separate paper files in the inpatient setting (e.g., clinician orders, nurses and other
ancillary staff documentation, prescription and medication administration records,
allergies, vital signs, laboratory and radiographic studies, problem lists, and
demographic information), into a single system and allow such information to be
imported into electronic clinical notes.
Real-time reminders and alerts can be incorporated into an EMR system including:
o reminders about health care maintenance (e.g., immunization timing),
o education (e.g., link to evidence-based guidelines), and
o error checks (e.g., alerts about allergies or potential drug interaction or incorrect
medication dosing).
Improved regulatory and security monitoring the EMR includes “meta-data” (such as
date and time stamps) and audit trail information that didn’t exist in the legal paper
record.[2]
Ease of quality improvement and research studies electronic data are more readily
accessible for quality improvement, public health, and research studies.
Potential challenges with current EMR implementation. The EMR theoretically promises to
improve efficiency and communication, reduce errors, and improve quality of care.[2] Yet,
every advance brings with it the potential for new problems, and the EMR is no exception.[3]
There are serious negative implications to poorly designed EMR systems, suboptimal EMR
implementation, or careless EMR use by clinicians. A poor quality medical record, which could
be inaccurate, inconsistent, incomplete, or obscure important information among unneeded or
redundant detail, may adversely impact current or future care, transfers of care, and/or
medico-legal investigations.[2] Problematic aspects of current EMRs include:
Increased work load: Data entry into the EMR can be time-consuming, particularly for
clinicians who do not type well.
Copy-paste: Electronically carrying forward or copying portions of previously written
notes and pasting them into a currently drafted note is problematic [2] when it is
either:
o Copying the work of others without attribution[3] (“clinical plagiarism”
[2] [11]) or
without independent confirmation.
Some clinicians rely on scribes or speech recognition software. Ultimately, the clinician is responsible for ensuring
that the medical record is accurate.
The US Department of Health and Human Services and the Office of the Attorney General have expressed
concern for fraud resulting from liberal copying-pasting within the EMR and subsequent upcoding, citing “possible
abuses including ‘cloning’ of medical records, where information about one patient is repeated in other records, to