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Health Record Overview
Patient record documentation has long been the responsibility of the provider, and it is still completed on paper by the majority of the practices in the United States. Hospitals and forward-thinking ambulatory care providers have been adapting electronic charting systems, known as electronic health record or electronic medical record software. The electronification of the patient records is only the first step. EMRs can bring additional decision support and patient safety measures to the provider's attention. Lab results and images can be exchanged electronically, and prescriptions can be sent automatically to the appropriate pharmacy.
As part of the American Recovery and Reinvestment Act, an incentive was put in place for hospitals and eligible providers to qualify for funds for their use of electronic charting systems. As CMS and the ONC have developed key criteria that advances the use of data, they have termed the program and requirements "Meaningful Use."
The system in place must meet certain criteria to be a "Meaningful Use Certified EHR." The vendors handle this certification. The providers have measures to meet then to qualify for the funds, with increasing requirements over the five or more years of the program.