Electronic Medical Record / Ambulatory Electronic Medical Record is a provider-centric or health organization-centric medical record of a patient in support of the provider’s interactions or encounters with the patient.
This computer-based record, maintained by clinicians on the patient, details the cumulative patient profile which includes elements such as demographics, medical and drug history, ongoing health conditions, risk factors, diagnostic information such as from laboratory results, and findings from diagnostic medical imaging, etc. The record will also include clinical notes, and consultation requests.
Other EMR functions and features include but are not limited to billing, scheduling, order entry for medications and tests, alerts, reminders, and clinical decision support.
The Electronic Medical Record (EMR) is typically used in a community physician practice setting by clinicians within a primary care practice or specialist physician practice. These EMR records are under the custodianship of a health care provider(s).
The Ambulatory Electronic Medical Record (aEMR) is typically used by a multi-disciplinary care team in an outpatient setting that has a direct affiliation with an inpatient facility. This record is under the custodianship of a health care organization.
Infoway's pre-implementation certification evaluates and assesses electronic medical records and ambulatory electronic medical records offered as a hosted service and/or as a product to be deployed at client sites.
Infoway's pre-implementation certification requirements are focused on four areas to evaluate EMR and Ambulatory EMR products:
- Privacy requirements (mandatory) are based on Infoway's Privacy and Security Conceptual Architecture, Government of Canada’s Personal Information protection and Electronic Documents Act; the Canadian Standards Association model code for the protection of personal information (CAN-CSA-Q830-03) as well as ISO 29100:2011 – Information technology – Security techniques – Privacy Framework.
- Security requirements (mandatory) are based on Infoway's Privacy and Security Conceptual Architecture as well as the International Organization for Standardization's (ISO) codes of practice for health information system security management (ISO 27799, ISO 17799, ISO 27001, ISO 27002, ISO 27005, ISO 27018, ISO 27789).
- Management control requirements (mandatory for hosted services) are based on the Canadian Standards Association’s Risk management: Guideline for Decision Makers – CAN-CSA-Q850-97, the Information Systems Audit and Control Association’s Control Objectives for Information and Related technology (COBIT) as well as the Information Technology Infrastructure Library (ITIL).
- Interoperability requirements (optional)
- Client Registry
- Clinical Reports