Electronic Health Records

Introduction

In this introduction, we will give a history of how computer-based patient record (an electronic medical record) evolved going back to the early 1960’s and define the concepts as we move forward.

Definitions [Ref] – From “Computer-Based Patient Record” Institute of Medicine

  • A patient record is the repository of information about a single patient. This information is generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowl­ edge of the patient (or with both). Traditionally, patient records have been paper and have been used to store patient care data.
  • A computer-based patient record (CPR) is an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems,3 links to medical knowledge, and other aids.
  • A primary patient record is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions.
  • A secondary patient record is derived from the primary record and contains selected data elements to aid nonclinical users (i.e., persons not involved in direct patient care) in supporting, evaluating, or advancing pa­tient care.4 Patient care support refers to administration, regulation, and payment functions. Patient care evaluation refers to quality assurance, utili­zation review, and medical or legal audits. Patient care advancement refers to research. These records are often combined to form what the committee terms a secondary database (e.g., an insurance claims database).
  • A patient record system is the set of components that form the mecha­nism by which patient records are created, used, stored, and retrieved. A patient record system is usually located within a health care provider set­ ting. It includes people, data, rules and procedures, processing and storage devices (e.g., paper and pen, hardware and software), and communication and support facilities.A patient record system can be part of a hospital information system, which typically handles both administrative and clinical functions, or a medical information system, which has been defined as “the set of formal arrangements by which the facts concerning the health or health care of individual patients are stored and processed in computers” (Lindberg, 1979:9).A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical informa­tion (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems).

Electronic Medical Record

[Edward H. Shortliffe and James J. Cimino (eds.), Biomedical Informatics, 4th ed. 2014,
Computer Applications in Health Care and Biomedicine, DOI: 10.1007/978-1-4471-
4474-8, © Springer-Verlag London 2014. Section 12 EHR]

An electronic record is a repository or electronically maintained information about an individual’s health status and health care, stored such that it can serve the multiple legitimate uses and users of the record. Traditionally, the patient record was a record of care provided when a patient was ill. Health care is evolving to encourage health care providers to focus on the continuum of health and health care from wellness to illness and recovery. Consequently, we anticipate that eventually, it will carry all of a person’s health-related information from all sources over their lifetime.

The term electronic health record system includes the active tools that are used to manage the information, but in common use, the term EHR can refer to the entire system. EHRs include information management tools to provide clinical reminders and alerts, linkages with knowledge sources for health care decision support, and analysis of aggregate data both for care management and for research. The EHR helps the reader to organize, interpret, and react to data.

EHR is not simply an electronic version of the paper record. A medical record that is part of a comprehensive EHR system has linkages and tools to facilitate communication and decision making.

The five functional components are:

1. An integrated view of patient data

2. Clinician order entry

3. Clinical decision support

4. Access to knowledge resources

5. Integrated communication and reporting support


What is an electronic health record (EHR)? 

Official Website of The Office of the National Coordinator for Health Information Technology (ONC)

An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can:

  • Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
  • Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
  • Automate and streamline provider workflow

One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.


What is the difference between EMR and EHR? [Ref]

What’s in a word? Or, even one letter of an acronym?

Some people use the terms “electronic medical record” and “electronic health record” (or “EMR” and “EHR”) interchangeably. But here at the Office of the National Coordinator for Health Information Technology (ONC), you’ll notice we use electronic health record or EHR almost exclusively. While it may seem a little picky at first, the difference between the two terms is actually quite significant. The EMR term came along first, and indeed, early EMRs were “medical.” They were for use by clinicians mostly for diagnosis and treatment.

In contrast, “health” relates to “The condition of being sound in body, mind, or spirit; especially…freedom from physical disease or pain…the general condition of the body.” The word “health” covers a lot more territory than the word “medical.” And EHRs go a lot further than EMRs.

What’s the Difference?

Electronic medical records (EMRs) are a digital version of the paper charts in the clinician’s office. An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to:

  • Track data over time
  • Easily identify which patients are due for preventive screenings or checkups
  • Check how their patients are doing on certain parameters—such as blood pressure readings or vaccinations
  • Monitor and improve overall quality of care within the practice

But the information in EMRs doesn’t travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record.

Electronic health records (EHRs) do all those things—and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.”

The information moves with the patient—to the specialist, the hospital, the nursing home, the next state or even across the country. In comparing the differences between record types, HIMSS Analytics stated that, “The EHR represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual.” EHRs are designed to be accessed by all people involved in the patients care—including the patients themselves. Indeed, that is an explicit expectation in the Stage 1 definition of “meaningful use” of EHRs.

And that makes all the difference. Because when information is shared in a secure way, it becomes more powerful. Health care is a team effort, and shared information supports that effort. After all, much of the value derived from the health care delivery system results from the effective communication of information from one party to another and, ultimately, the ability of multiple parties to engage in interactive communication of information.

Benefits of EHRs

With fully functional EHRs, all members of the team have ready access to the latest information allowing for more coordinated, patient-centered care. With EHRs:

  • The information gathered by the primary care provider tells the emergency department clinician about the patient’s life threatening allergy, so that care can be adjusted appropriately, even if the patient is unconscious.
  • A patient can log on to his own record and see the trend of the lab results over the last year, which can help motivate him to take his medications and keep up with the lifestyle changes that have improved the numbers.
  • The lab results run last week are already in the record to tell the specialist what she needs to know without running duplicate tests.
  • The clinician’s notes from the patient’s hospital stay can help inform the discharge instructions and follow-up care and enable the patient to move from one care setting to another more smoothly.

So, yes, the difference between “electronic medical records” and “electronic health records” is just one word. But in that word there is a world of difference.

Was this blog post helpful for you? Please comment below and let us know if there are other ways we can help spread the word about the EHR/EMR difference


Patient Health Record [Ref]

Electronic personal health record systems (PHRs) support patient-centered healthcare by making medical records and other relevant information accessible to patients, thus assisting patients in health self-management.

Because primary care physicians play a key role in patient health, PHRs are likely to be linked to physician electronic medical record systems, so PHR adoption is dependent on growth in electronic medical record adoption. Many PHR systems are physician-oriented, and do not include patient-oriented functionalities. These must be provided to support self-management and disease prevention if improvements in health outcomes are to be expected. Differences in patient motivation to use PHRs exist, but an overall low adoption rate is to be expected, except for the disabled, chronically ill, or caregivers for the elderly. Finally, trials of PHR effectiveness and sustainability for patient self-management are needed.


What is “My Health Record?” – From Australia

My Health Record is a secure online summary of an individual’s health information and is available to all Australians. Healthcare providers authorised by their healthcare organisation can access  My Health Record to view and add patient health information.

Through the My Health Record system you can access timely information about your patients such as shared health summaries, discharge summaries, prescription and dispense records, pathology reports and diagnostic imaging reports.


International overview of digital health record systems

LINK

Fragidis L, Chatzoglou P. Implementation of a nationwide electronic health record (EHR): The international experience in 13 countries.International Journal of Health Care Quality Assurance. 2018;31(2):116-130.

Findings – Taking into account the heterogeneity of each country’s financing mechanism and health system, the predominant EHR system implementation option is the middle-out approach. The main reasons which are responsible for adopting a specific implementation approach are usually political. Furthermore, it is revealed that the most significant success factor of a nationwide EHR system implementation process is the commitment and involvement of all stakeholders. On the other hand, the lack of support and the negative reaction to any change from the medical, nursing and administrative community is considered as the most critical failure factor.