What is an EHR (Electronic Health Record)?
An electronic health record (EHR) is a digital collection of an individual’s overall medical data. It’s collected and managed by a variety of authorized providers and can be shared electronically among them. Instead of just information from a single doctor’s visit or a single provider, it includes a complete medical history, demographic data, and clinical information such as diagnoses, medications, immunizations, allergies, and lab results.
The EHR has the ability to support other care-related activities directly or indirectly, including evidence-based decision support, quality management, and outcomes reporting. EHRs effectively allow communication and coordination among members of a healthcare team for optimal patient care, but especially when providers are with patients.
The availability of information from the EHR during a patient visit is an invaluable tool. The provider has access to graphs, medical images, test results, and anatomical drawings, all of which are useful in explaining something related to the patient’s condition or illustrating an upcoming procedure.
Experience has shown that patients respond well to the use of a computer and EHR system during the exam, especially when they’re part of the process, able to see the screen, and able to participate in the review of their information. With EHRs, patients and doctors share information to determine the best plan for given conditions.
History of the EHR
Prior to the 1960s, all medical records were paper records, manually filed. All doctor’s visit information, from diagnoses, lab reports, and notes, were written and maintained on paper, bound together, physically labeled as the patient’s medical record, then filed and retrieved from shelves.
In the mid-60s, with the dawn of the computer era, many of the earliest computer applications were in use at hospitals but few other places. These institutions used Electronic Medical Records (EMR). This is the digital version of the patient chart that was contained and ONLY used within the hospital or provider’s office.
In the 80s, computers gained traction in smaller facilities and clinics at the same time computers were gaining traction with the general public. With the internet, change became far more visible, and the internet became an essential tool for recording and transferring medical records. As more and more providers were implementing EMRs within their practice, focused efforts were made to increase the use of EHRs among medical practices for enhanced communication among providers.
Eventually, individuals became accustomed to accessing their sensitive information online through secure networks (banking, stock trades, boarding passes) and also wanted to be able to access their medical records online as well.
By 2004, there was national recognition of the industry’s need to convert individual medical records to EHRs with the creation of The Office of the National Coordinator of Health Information Technology. Shortly after, EHRs were incorporated into the Health Information Technology for Economic and Clinical Health Act (HITECH), which offered higher payments to providers that met “meaningful use” criteria.
What is “meaningful use”? As defined by HealthIT.gov, “Meaningful use” would achieve the following:
- Improve quality, safety, efficiency, and reduce health disparities and errors
- Engage patients and families
- Improve care coordination and public health
- Maintain privacy and security of patient health information
In 2009, as a part of the American Recovery and Reinvestment Act, all public and private healthcare providers were required to demonstrate “meaningful use” by January 1, 2014.
HIPAA regulations were also adjusted to account for and protect the electronic health information that was being maintained by these EHRs, and you begin to see today’s version of EHRs: secure, effective tools for providers to maintain patient’s healthcare data and communicate with a team of other providers.
Keeping Your Information Secure
Although EHRs are more comprehensive and secure than ever before, security upgrades and refinements at all access points are at the forefront of public and private sectors.
The HIPAA Security Rule requires providers to set up physical, administrative, and technical safeguards to protect your information which could include:
- “Access controls” such as passwords and PIN numbers,
- “Encrypting” so your stored information can only be viewed by authorized people who have a special key,
- An “audit trail,” which records who accessed your information, what changes were made and when.
Cloud-based EHR vendors have integrated their EHRs with security and protection protocols. These include data encryption, remote storage, and back up data.
A key to preserving confidentiality of your information within the EHR system is making sure that only authorized individuals have access to that information. The process of controlling access starts with authorizing the users. For example, a nurse and a receptionist within a practice would not have the same level of access to patient information.
Because medical practice is increasingly information-intensive, creating secure EHRs requires the expertise of physicians, clinicians, technology professionals, administrative personnel, and patients as well.
What is the Difference Between an EHR and an EMR?
While an EMR contains comprehensive information and records of the patient’s history with one provider, the EHR contains all of this AND it is sharable amongst authorized providers, health organizations, and clinics. An EHR goes beyond the information from just one provider and includes a comprehensive patient history which can be shared amongst all providers to help coordinate care for the patient.
Though they are different, you may frequently find EHR used instead of EMR. To clarify, here are some key differences between the two systems:
EHR vs. EMR
|A digital version of a patient chart||A digital record of all patient health information|
|Patient record does not easily travel outside the practice and might need to be printed||Allows a patient’s medical information to move with them to other health care providers and specialists|
|Mainly used by a provider for diagnosis, treatment and care||Accessed by any number of providers for decision making, diagnosis and care beyond one provider’s office|
Both are necessary on the continuum of care for a patient. The EMR provides a comprehensive record of care within a practice and the EHR makes that care accessible to a variety of healthcare providers, even hospitals, if and when needed.
The Advantages of an EHR
Benefits of EHRs for PATIENTS:
- Fewer errors on medical records
- Quicker assessment and care from medical professionals
- Improved health diagnosis, treatment and overall quality of care
- Enhanced privacy and security of patient data
- Reduction in patient errors and improved patient care
- Enable evidence-based decisions at point of care
- Follow-up information after a visit such as self-care instructions, reminders for other follow-up care, and links to web resources
- Access to patient’s own records to view medications and keep up with lifestyle changes that have improved their health
Benefits of EHRs for CLINICS:
- Save space by eliminating paper records needing to be stored, managed and retrieved
- Reduce administrative difficulties and operational costs
- Interface easily with hospitals, pharmacies, labs and state health systems
- Improve documentation and coding
- Enhance research and monitoring for improvements in clinical quality
- Provide built-in safeguards against prescribing treatments that would result in adverse events
- Track electronic messages to staff, other clinicians, hospitals, labs, etc.
- Links to public health systems such as registries and communicable disease databases
Beyond the improved systems and quality of care for patients, there are also financial advantages to EHRs. A clinic’s operational costs and overtime labor expenses are reduced due to the overall efficiency of workflow. Additionally, the ability to more accurately and efficiently process patient billing improves the clinic’s bottom line.
Any disadvantages of electronic records are not necessarily in the system itself, but in the initial (and natural) challenges of investment, preparation and training in the system.
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