Early Terms and Definitions Multiple labels and definitions
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Early Terms and Definitions Multiple labels and definitions have been used throughout the years to refer to electronic systems used in healthcare. Early terms focused on using the words computer and record to merge the idea of a paper chart with technology, but computers provided much more functionality than did traditional methods. These early terms were not sufficient to describe this emerging phenomenon. For example, specific terms and acronyms such as computer patient records (CPRs), computer-based patient records (CBPRs), and computer health records (CHRs) were used to identify systems that contained select automated components of the patient’s medical record. The acronym CPR was not popular in the health community because it also represents the term cardiopulmonary resuscitation. Generic names such as hospital information system (HIS) or medical information system (MIS) were adopted to represent the management of a larger body of data and information throughout a specific hospital or healthcare system.
Later definitions for electronic systems in healthcare often focused on the system’s distinctive purpose, content, ownership, and functional differences. This is especially true for technology used in specialty areas such as nursing, pharmacy, laboratory, radiology, and other support departments. For example, a laboratory information system (LIS) would be used to collect, store, process, and manage laboratory data and would be controlled by the laboratory department personnel, whereas a pharmacy system would provide medication inventory, control, and dispensing for pharmacy personnel. Specific clinical departmental systems will be discussed in more detail later in the chapter. Acronyms such as CBPR or CPR referred to a larger collection of information about the patient, such as orders, medications, treatments, laboratory and diagnostic test results, and other information related to overall patient care. Although the terms imply a patient-owned record, access and input to the record are typically controlled by the healthcare provider. As computer technology continued to progress and more functionality became available, a need surfaced for clarity and refinement in terms and definitions relating to EHR systems.