The Stages of Recognition in EMR

An Electronic Medical Record is a complex application environment that supports a patient's record of inpatient and outpatient services provided within a care delivery organization. It is the legal record of what happened to the patient, and is owned by the CDO. Transforming a CDO to a complete EMR system happens in seven progressive stages. The majority of hospitals in the U.S. are in the early stages of transformation, with about 50 percent at Stage 2.

Stage 0

• In the beginning stage, ancillary services such as pharmacy, radiology and laboratory do not maintain electronic recording systems.

Stage 1

• Electronic systems records are in place in ancillary services such as pharmacy, radiology and laboratory.

Stage 2

• Data from the ancillary systems feed into a clinical data repository (CDR) and the medical vocabulary is controlled to maintain consistency. Imaging data may also be linked to the CDR at this stage. At this stage, the CDO is capable of health information exchange (HIE), so it's possible to share CDR data with other patient care stakeholders.

Stage 3

• Nursing and clinical documentation is required for this stage. Nurse notes, care plan charts, and electronic medication administration records are recorded electronically and integrated with the CDR. The first level of critical decision support begins to conduct error checking with order entries. Medical image information may be accessed by physicians outside of the radiology department through a CDO Intranet.

Stage 4

• Computerized practitioner/physician order entry (CPOE) adds to the CDR. At this stage, the second level of critical-decision support that's related to evidence-based medical protocols is in place. If any medical service area implements CPOE and completes the previous stages, this level is achieved.

Stage 5

• The closed loop medication administration environment is fully implemented in Stage 5, and auto identification technology is in place and shared with CPOE to ensure patient safety in drug administration.

Stage 6

• Full physician documentation and charting is in place for at least one patient service area. Level three of critical-decision support offers guidance for all clinical activities relating to outcomes and protocols, in the form of variance and compliance alerts. Digital images replace film images and are accessible through the Intranet.

Stage 7

• The hospital no longer uses paper charts to deliver and manage patient care, and maintains a mixture of discreet data, documents and images within the EMR environment. Data warehouses are available to analyze patterns, and improve quality of patient care and safety. Information can be shared and exchanged with all entities authorized to care for a patient. Hospital data about the patient is consistent throughout departments and services.