Understanding Electronic Medical Records

When you visit a health care provider, important medical information-€”such as laboratory and imaging test results, prescriptions, and recommended treatments-€”becomes part of your medical record. Some medical records may be kept in paper form. However, an increasing number of health care providers are using electronic medical records (EMRs).

What is an electronic medical record?

An EMR is a digital record of a person's medical history that can be shared electronically between health care providers within a medical practice or hospital. Unlike a paper record, all members of the health care team can quickly access a patient's medical record from anywhere, at any time, via a secure Internet connection. An EMR may be owned either by the medical provider (doctor) or by the institution (hospital).

The term EMR often is incorrectly used interchangeably with EHR (electronic health record). Although the two terms are similar, the EMR is the legal, provider-owned source of patient health information (such as test results and prescription entries) for a single medical practice or hospital. The EHR, on the other hand, is the portion of patient records that is shared between medical practices or hospitals that a patient can own and edit.

Benefits of an EMR

EMRs are part of a larger effort led by the U.S. Department of Health and Human Services to computerize health information. Both former President George W. Bush and President Barack Obama have emphasized the importance of EMRs, and the federal government announced both financial incentives and penalties to encourage doctors, hospitals, and clinics to adopt computerized systems. EMR supporters believe these records can improve patient health care by:

Preventing medical errors. Because EMRs are computerized, they may help reduce medical errors caused by handwriting that is difficult to read. EMRs may also notify members of the health care team when a prescribed medication may harmfully interact with another medication a patient is taking or when a patient has a drug allergy.

Reducing health-care costs. EMRs may save patients and health care providers money in multiple ways, including preventing duplication of expensive imaging and laboratory tests and eliminating costly paperwork.

Reducing delays in treatments. EMRs make it possible for members of the health care team to quickly search for and find information, such as test results. This can improve the efficiency of communication among members of the health care team so that treatment is not delayed.

Reducing office wait times. EMRs may improve office efficiency by eliminating the need for patients to fill out health forms each time they see their health care providers. EMRs may also reduce the need to search through numerous paper files for patient information.

Improving communication between the health care team and patients. When members of the health care team have immediate and complete access to a patient's information, patients may receive more timely responses to questions. EMRs may also shorten the time a patient has to wait for a phone call to be returned or a prescription to be filled. Some EMRs also provide detailed post-visit summaries and instructions for patients.

Ensuring continuity of care. EMRs may help ensure that people with complex diseases, such as cancer, receive the care they need. For example, the health care team can closely track treatment schedules in EMRs, which can help doctors to avoid, detect early, or efficiently manage long-term treatment side effects if they have all of the information they need about a patient's diagnosis and treatment.

Privacy and your EMR

Medical information and records are protected under the federal Health Insurance Portability and Accountability Act (HIPAA). With some exceptions, this act states that medical information collected on patients cannot be shared unless a patient gives permission for the information to be released. HIPAA also gives you the right to see or obtain a copy of your medical records, even though they are owned by your doctor or the hospital.

Personal health records

Not every health care provider uses EMR and some health care providers aren't able to share EMRs because they use different data systems that do not communicate with each other. The American Society of Clinical Oncology (ASCO) and other organizations are working on creating technology standards that would allow information in different EMR systems to be shared more easily. In the meantime, personal health records (PHRs) are becoming important tools for patients to keep a detailed record of medical care.

Unlike an EMR, which is owned and updated by health care providers as required by law, you are responsible for collecting and maintaining the information in your PHR. A PHR does not replace legally required medical records. Creating a PHR is voluntary, not mandatory. Learn more about creating a personal health record.

ASCO and EMR activities

A person with cancer may need numerous tests and treatments. In addition, cancer survivors need a detailed long-term plan for follow-up care that may involve multiple doctors at multiple locations. To ensure your ongoing good health, it is critical that health care providers have your complete medical history that is available anytime. ASCO established a series of initiatives to speed the adoption of EMRs by oncologists (doctors who specialize in treating cancer).

ASCO developed the Health Information Technology (HIT) Work Group, which provides resources to help oncologists choose and use an EMR and guidance on a variety of EMR issues. ASCO is also working with EMR vendors to ensure that their products meet the complex requirements of people with cancer.

More Information

Organizing Your Cancer Care

Medical Forms

Additional Resources

Centers for Medicare and Medicaid Services: Electronic Health Records

Department of Health and Human Services: Electronic Health Records: Improving America's Health Care

Department of Health and Human Services: Personal Health Records and the HIPAA Privacy Rule

American Health Information Management Association: My PHR