The Electronic Medical Record

Abstract

1. Mark Simonian, MD* 1. *Chair, Council on Clinical Information Technology, American Academy of Pediatrics In 1991, the Institute of Medicine's “Report on the Computer-based Patient Record” addressed the value of the electronic record. Many basic elements were highlighted and included legible and sortable patient information, access to support for clinical decisions, entry of orders and data, enhanced communication from consultants, clinical studies about the epidemiology of medical injuries, and access to administrative data. All of these elements are expected to improve workflow, reduce errors, and provide cost savings. (1) President Bush has said in addresses to Congress that all patients will have electronic health records by 2014. (2) His administration, with bipartisan support, has established a National Health Information Technology Coordinator Office to advise the Secretary of Health and Human Services. (3) That group helps promote development and establishes standards to make health records digital and interoperable and assures that the privacy and security of the records are protected. (4) The American Academy of Pediatrics (AAP) first addressed the uniqueness of a pediatric electronic medical record when it published a policy statement in 2001. (5) In 2007, the policy statement was updated as a clinical report, describing additional pediatric-focused details. (6) This report is much more useful in assisting electronic medical record (EMR) vendors and organizations that establish standards to design systems that have elements critical to pediatrics and brings better value to a pediatric practice. Many elements are functionally important in pediatrics, such as immunization management, growth tracking, medication dosing, and patient identification. Pediatric norms need to address data elements such as numeric and non-numeric information, complex normative relationships, gestational age, adoption, guardianship, and emergency treatment. Privacy status and sensitive information have unique ramifications in pediatrics and include elements relating to adolescent privacy, children of foster or custodial care, and consent for proxy. Pediatric terminology is of paramount importance when relating …