The Electronic Medical Record (EMR) is not a new system in the documentation of patients’ medical records. Electronic Medical Record is a system that contains the patient’s medical history and illness, the results of diagnostic tests, other medical data and information on treatment costs.
EMR will improve health services by service providers in patient care, but health service managers must incur high costs to provide information technology systems to use EMR.
Implementation cannot occur suddenly but requires a long time. EMR implementation is a big process and project from the information technology system because it is full of challenges.
Managers cannot always accept challenges and manage effectively and critically in order to make changes to new information systems and technologies. In the end, new electronic information technology is expected to improve privacy and confidentiality.
EMR has been used in various hospitals in the world as a substitute or complementary to paper-based health records. Since the development of e-Health, EMR has become an information center in hospital information systems.
EMR is an activity to computerize the contents of a medical record and and process related with it. Medical records that contain information on evaluating physical condition and patient’s medical history are very important in planning and coordinating patient services, for further evaluation and ensuring continuity of services provided. Therefore, the completeness, accuracy and timeliness of filling must be sought in health organizations because it is very important for the feasibility of service actions and referrals.
EMR is not an information system that can be purchased and installed such as word-processing packages or payment information systems and laboratories that can be directly linked to other information systems and appropriate tools in a particular environment. EMR is an information system that has a broader framework and meets a set of functions and must meet the following criteria:
- Integrated data from multiple sources
- Capture data at the point of care
- Support caregiver decision making
The EMR is contained in a system specifically designed to support users with various facilities for completeness and accuracy of data, alerting, warning, having a system to support clinical decisions and linking data with medical knowledge and other assistive devices. WHO also has different views on the notion of EMR, which is based on several differences in the application of EMR in several countries. However, WHO explained that the EMR should ideally be able to:
- Collect clinical, administrative and financial data at the point time
- Exchange data more easily between health professionals to facilitate continuing care
- Measure clinical improvement and health outcomes, compare the outcomes againts benchmarks and facilitate research and clinical trials
- Provide valuable statistical data in a timely and efficient manner to public health and goverment ministries (such reporting of health data is important in the detection and monitoring of disease outbreaks, as well as providing meaningful and accurate statistics to measure the health status of the population; and Support management in administrative and financial reporting and other processes.