AMR (Ambulatory Medical Record) Submits IPO Prospectus, Pioneering Digital Outpatient Documentation in Internet Healthcare

What Is AMR?

AMR (Ambulatory Medical Record) refers to the electronic outpatient medical record of a patient, which includes all surgical procedures and medical care received by the patient without hospitalization.

AMR andEMR (Electronic Medical Record)Similar, but electronic medical records document the process of inpatient treatment (surgeries and care involving overnight stays or longer hospitalizations), whereas AMR applies only to patients who do not require hospitalization after diagnosis and treatment, such as those receiving emergency care or home healthcare services.

AMR data is stored in an electronic database known as AMRS (Ambulatory Medical Record System). Physicians and other healthcare professionals can access this system. When integrated with EMRS (Electronic Medical Record System), AMRS enables physicians to view a patient’s complete and accurate medical history.

Outpatient medical record management is not merely the custodianship of patient health records. Through the scientific design of outpatient medical histories and clinical examination items, it can effectively guide clinicians in their medical practice, serving as a behavioral guideline for accurate disease diagnosis. It not only plays a role in quality control and management of medical activities but also serves as valuable data for clinical scientific research.

Major Components of AMR

1. Patient's basic information, such as age, gender, insurance, etc.
2. Relevant Medical History
3. Laboratory results, radiology reports, rehabilitation therapy records, and outpatient surgical procedure documentation
4. Discharge summaries, pathology reports, etc.
5. All original documents must be scanned and uploaded to the outpatient medical record system.

The Operating Model of AMR

1. Only physicians are permitted to perform the procedure
In this mode, physicians input patient demographic and clinical data, a process that requires little to no assistance from others. Data can be entered via structured templates, with the option to freely add free-text notes as needed. Upon successful data entry, the physician generates a clinical note for the patient; additionally, the system allows the physician to send referral letters to consulting physicians.

2. Frontend Support
This model is the dominant mode of AMRS. With the assistance of clinical and administrative staff, physicians enter patients' basic and medical data. Clinical staff, including clinical nurses, physician assistants, and medication assistants, document key information such as chief complaints, allergy history, medication usage, and vital signs, generating a clinical report for physician review. Subsequently, if needed, physicians can supplement the medical record by adding additional information online.

3. Oral Statement
In this model, when an outpatient visits the clinic, the physician dictates a clinical diagnosis report. The physician’s assistant then creates a medical record for the new patient and enters the report into the Ambulatory Medical Record System (AMRS) via computer software. The primary advantage of this approach is enhanced continuity of medical records, enabling other physicians to access the patient’s prior visit information through the AMRS during subsequent consultations.

Advantages of AMR

1. Ensures the systematic and complete documentation of patient medical history
In the United States, outpatient medical records are centrally managed by hospitals, with management protocols equivalent to those for inpatient medical records in China. All medical record data are entered into computerized systems, eliminating the loss of outpatient medical histories and preserving patients’ health archives in their entirety. This facilitates future reference and enables physicians to gain a comprehensive understanding of patients’ conditions, thereby ensuring continuity of care.

2. Facilitates Quick Search
Professionally designed medical record coding enables staff to quickly and accurately locate patient-related information. By simply providing the patient’s ID number, outpatient medical records can be precisely retrieved.

3. Saves physicians’ time and facilitates documentation
Thanks to the tabular and standardized format of medical records, physicians need only select options or fill in blanks, which saves clinical time and reduces transcription errors caused by illegible handwriting.

4. Facilitates accurate and error-free physician diagnosis
The comprehensive and systematic design of medical record forms, particularly the structured system for collecting medical history, symptoms, and signs from initial-visit patients, minimizes omissions during clinical examinations, lays a foundation for accurate diagnosis, and prevents misdiagnosis and missed diagnoses at the source.

5. Facilitates the establishment of a stable relationship between doctors and patients
Detailed medical records captured during a patient’s initial hospital visit facilitate future follow-up consultations and help establish a long-term, stable relationship between the hospital and the patient.

6. Contributes to Medical Advancement
Outpatient medical records are designed by professionals to include history-taking and examination items with scientific research value, thereby providing primary data for future summarization and analysis, which facilitates medical research and development. Under the premise of ensuring patient privacy, this approach enables society-wide sharing of medical information and avoids resource waste, thus promoting medical advancement while safeguarding patients’ legitimate rights and interests.

Current Status of Outpatient Medical Record Management in China

With the release of standards such as the “Functional Specifications for Electronic Medical Record Systems” and the “Grading Evaluation Methods and Standards for Functional Application Levels of Electronic Medical Record Systems,” an increasing number of hospitals have adopted electronic medical record (EMR) systems. However, most hospitals limit their use to inpatient EMRs, while outpatient EMRs continue to rely on the traditional handwritten model.

In China, outpatient medical records are currently categorized into two types: electronic and handwritten. Handwritten records fall into two subcategories: those individually designed by hospitals and standardized templates issued by municipal medical insurance offices. Generally, electronic outpatient medical records are designed according to each hospital’s internal system, primarily to facilitate documentation by physicians as well as statistical analysis and archival by the hospital. In contrast, handwritten records typically consist of brief notes made by physicians and are retained by patients themselves. Due to the unique nature of outpatient medical records, many hospitals in China have not established a unified custodial protocol. These records may be kept either by healthcare institutions or by patients. Consequently, in the event of disputes, hospitals face significant challenges in meeting their burden of proof, particularly regarding issues of informed consent.

By Liu Nan | Edited by Mo Renying