By Michael R. Kauka

Almost every day I am approached about our products and services with a question similar to "Is your software a CPR or an EMR? And can it work with EHR?" I typically take a deep breath and answer "Yes". At this point a customer will look at me concerned I lost my mind and I continue ... "but..."

Below is my extended explanation of 'but'. First the short one:
The principal idea of all these concepts (EHR, EMR, CPR) and the resulting software is principally the same. Most of us know that the electronic medical record is here. Many of us understand some of its advantages. Few of us understand the electronic medical record's current reality. If at all possible, use electronic medical record software. But go slow and tread carefully.

Here comes the lengthier explanation. Choices are confusing for a healthcare provider in the age of the electronic record. This article does not mean to promote any one system, or even one method. The choices are too complex for the circumstances of a particular provider to be covered in one article. However, a basic understanding of the underlying concepts may be useful in recognizing what is needed today and may very well help you avoid costly mistakes and disappointments.

A (Very) Brief History
People started talking about something called the electronic health record in the 60s. But computers were practically nonexistent. Then, in 1991, a report by the Institute of Medicine introduced a more precise concept of the computer-based patient record and its importance to future medicine. It was the first report to pioneer the idea of a computer-based, longitudinal, life-long, integrated patient record including entries from all healthcare providers. The benefits of an electronic patient record became immediately obvious:

Electronic Record: Benefits
Moving from paper to the electronic record has significant advantages:

1. It allows for simultaneous, remote access to patient data by all authorized providers.
2. It facilitates faster and better communication among providers.
3. It reduces errors which results in better health care and lower cost.
4. Electronic systems facilitate safer data and improve patient data confidentiality.
5. It allows for flexible data layout and therefore integrates easier with other information resources.
6. It allows for incorporation of various related electronic data, and records are may be continuously processed and updated.
7. It makes the searching and finding of data considerably easier.

Wonderful, right? However, making these advantages reality is another matter. To this date no system, encompassing all these advantages, exists.

The First Attempt: Computerized Patient Record (CPR)
The first attempt at electronic records was the computerized patient record, or computer based record, CPR. The basic idea behind CPR is a computer-based medical record system that includes all information (clinical and administrative) for one patient and covers all practitioners ever involved in a that person’s health care. The CPR established the foundation for the vision of all systems that were to follow: the CPR as a basis for and an integral part of decision support.
The concept and vision failed, mainly due to:

• No electronic data standards - not yet, and not for the foreseeable future;
• Disparate information systems - notice the term "allows" in the list above. As of today, it is highly unlikely that the health information system of a provider in LA is communicating with that of a provider's HIS in Atlanta;
• Privacy concerns - who decides who has access to what?
• A national data bank is currently politically unacceptable as keeping track of each patient requires an unique patient identifier, or ID.

So, we're left with a CPR system today, that basically consists of some records on some computers:

THE AUTHOR'S DEFINITION OF CPR TODAY:
CPR is a record about an individual patient stored in a healthcare provider's computer, in a database that is typically the property of the provider. It will usually contain the patient's demographic data and medical information collected only when the patient visits that provider.

Moving On : Electronic Medical Record (EMR)
This is presently the catch-all phrase for medical records existing on millions of hard drives. It is also the most misunderstood term. Software companies adopted it as an all encompassing term for medical records created and stored in an electronic format. In its originally conceived intent, the EMR is similar to the CPR:

THE AUTHOR'S DEFINITION OF EMR TODAY:
An electronic medical record system (sometimes referred to as EPR - electronic patient record) is an organized collection of all records about an individual patient stored in the computer systems and databases of all the providers who have provided care to that patient within one enterprise. The EMR is not stored on any one individual computer, but is assembled dynamically, in real time, from various systems when needed.

The EMR eliminates the optimistic goal of the original CPR concept of universal access and aims at a more achievable approach of sharing patient information from different systems among authorized professionals within an organization. How is it different from the more real "Today's Definition" of CPR"? Not much. I know ... a little more explanation is needed.

Reality Hits Again
As the original objective of CPR became impossible to realize, the simple process of storing records on PCs became reality. It delivered a few of the anticipated advantages. CPR became synonymous with storing medical records on a PC and, sometimes, importing them into databases. Time passed and the Internet became famous. Lots of new possibilities. Data could be transmitted across systems and around the world within seconds. Although a significant step towards the original idea of the CPR was taken, the term had become synonymous with old technology. The term EMR was born. It is CPR's big brother with lots of "extras" -- which makes defining EMR as a standard approach difficult. EMR is defined by software manufactures. And they define it by features, not as an approach to patient documentation.

A medical records manager's view of an EMR is probably the closest to what it should be: a system that securely stores patient information, may be accessed by the staff from various locations, and can import / export or consolidate information to and from other systems such as practice management systems, scheduling, billing, imaging and so on. Most clinicians look at it as a possible time-saver because many EMR systems compliment dictation with point-and-click entry, prescription writing, and some automated report generation. Administrative managers may look at an EMR system as a replacement for practice management systems ... and so on. The definition of an EMR within today's market place varies as much as there are products available.

There is no EMR standard today. Actually, there still aren't ANY standards. Which isn't stopping anybody from talking about the next possible standard.

The Future? Electronic Health Record (EHR)
The relatively new concept of electronic health record (EHR) avoids some of the controversial aspects of the CPR, such as the unique identifier. It also attempts a more realistic approach in regards to the exchange of information among various organizations while promoting full interoperability among specialties. However, the process of achieving data standards to meet even only the most important requirements of an EHR have proven to be complex. And although a number of respected institutions and companies are working on standards, at this time EHR is still a concept of the future.

THE AUTHOR'S DEFINITION OF EHR TOMORROW (or the day after ...):
An EHR (electronic health record system) describes (at least as of today) a longitudinal record of patients' health healthcare - from cradle to grave. It combines both the information about patient contacts with primary healthcare as well as subsets of information associated with the outcomes of periodic care whether held in EMRs, CPR's or other information systems.

Now What?
Very general advise:

• Go electronic. Even if only 1 out of 10 advantages of going electronic are met, it is much better than a paper-based system.
• Take small steps. Start with a complex system and the chances are the resulting problems will be complex.
• Go with a web-based system. The Internet is the "great communicator". XML-based systems (despite a lot of hype) will probably be the only standard for a long time to come.
• Focus on internal communications of systems. Worry about outside systems later.
• Spend as little money as possible. Things will change.
• Consider features as ... features. They probably make your life easier but they may or may not have anything to do with advancing the benefits of the electronic medical record, or computerized patient record or the electronic health record ... or the continuity of care record ... oh, that's another one.

This industry is changing rapidly. Technology is important in patient care, but look at it as a facilitator and not a solution. Stay tuned.

Michael Kauka is the CEO of Avaz Group LLC, a leading provider of patient documentation services and technology. And a vocal proponent of electronic records -- by any name -- and of standards of data. Questions or comments? .