Electronic Medical Records

All of Lesson 4

Electronic Medical Record (EMR)

This holds all patient records in one computer system

Electronic Health Record

This holds the medical information of a single patient

Discrete Data

Data with numeric value (blood pressure, pulse, lab results, etc)

This is the year the government pushed for the use of EMR’s nationwide

2010

Health Information Exchange (HIE)

Allows providers to access and share medical records electronically

Controlled Vocabulary

A set of terms medical providers must use to maintain understanding (think how all doctor’s know the meaning of hypotension, it’s the same across the board)

SNOMED CT

Contains the vocabulary for clinical terms (ex: hypertension)

LIONC

Contains the vocabulary for codes and identifiers

RxNorm

Contains the vocabulary for drugs and prescriptions

Health Level 7 (HL7)

Aims to increase the effectiveness and efficiency of healthcare information

Personal Health Record (PHR)

A system where the medical record is completely patient created and maintained

Electronic Data Management System (EDMS)

A hybrid system that utilizes both paper and electronic records