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Medical Records Then and Now

Advances in technology have brought about changes in every aspect of our lives, with many of these changes affecting the health care industry. A major advancement in the health care industry has been the change from paper-based medical records to electronic health records (EHRs) and electronic medical records (EMRs).

How have medical records changed?

When you went to see a doctor years ago, he or she made notes on your visit using a paper tablet and ink pen. These notes were kept in a binder or folder and stored in a file cabinet. As time passed, medical records were recorded onto cassettes and tapes, which were also stored either in file cabinets or medical vaults. In recent history, medical information has been stored on computers.

While all these records may have been detailed, they were also subject to loss due to fire, theft or other unforeseen circumstances. EHRs and EMRs, on the other hand, are safely stored and filed electronically and can be retrieved from almost anywhere.

What are electronic medical records?

Electronic medical records are digital versions of a patient’s medical history. When you visit your doctor, he or she likely types notes about your diagnosis and any treatment he or she prescribes. The record then goes to billing and coding specialists who determine your bill by assigning a specific code for each treatment you received. Your bill is then sent electronically. Your EMR stays in your physician’s office and is used each time you visit this doctor. He or she can easily look up your past visits on your electronic medical record.

What are EHRs?

Although many people think of EMRs and EHRs as being the same, they’re similar yet also different. While EMRs stay with the one physician you visit, your electronic health record does not. Your EHR has the results of your latest visit with your physician but also has visits you’ve had with other physicians, even at other clinics. If your doctor recommends that you see a specialist, your electronic health record will go to the specialist and any other medical professional you may see. EHRs also provide a more comprehensive medical history than EMRs.

What are the advantages of EHRs and EMRs?

  • These medical records make it quicker and more convenient for medical professionals to enter and retrieve patient information.
  • EHR software includes templates that require more thorough entry of medical data, which is beneficial if a patient has several medical conditions.
  • EHR software allows for medical code usage, making patient billing more timely and accurate.
  • EHRs provide for faster patient processing.
  • These medical records have less chances of being lost in a fire, vandalism or theft.

What are the disadvantages of EHRs and EMRs?

  • Data loss in case of computer crash if an adequate backup source is not implemented
  • Possibilities of identity theft by hackers and cyber criminals
  • Privacy can become an issue because many people may have access to the computer system
  • Lack of standardization and the “personal touch”
  • Too automated and lacking human management
Last Updated: February 10, 2016