Electronic Health Records in NutShell

The Basics

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.

Benefits of Electronic Health Records

Our world has been radically transformed by digital technology – smart phones, tablets, and web-enabled devices have transformed our daily lives and the way we communicate. Medicine is an information-rich enterprise. A greater and more seamless flow of information within a digital health care infrastructure, created by electronic health records (EHRs), encompasses and leverages digital progress and can transform the way care is delivered and compensated. With EHRs, information is available whenever and wherever it is needed.1

The Health Information Technology for Economic and Clinical Health (HITECH) Act, a component of the American Recovery and Reinvestment Act of 2009, represents the Nation’s first substantial commitment of Federal resources to support the widespread adoption of EHRs. As of August 2012, 54 percent of the Medicare- and Medicaid-eligible professionals had registered for the meaningful use incentive program.1

When fully functional and exchangeable, the benefits of EHRs offer far more than a paper record can. 

EHRs:

• Improve quality and convenience of patient care
• Increase patient participation in their care
• Improve accuracy of diagnoses and health outcomes
• Improve care coordination
• Increase practice efficiency and cost savings

Transformed Health Care

Electronic Health Records (EHRs) are the first step to transformed health care. 

The benefits of electronic health records include:

• Better health care by improving all aspects of patient care, including safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity.
• Better health by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventative care.
• Improved efficiency and lower health care costs by promoting preventative medicine and improved coordination of health care services, as well as by reducing waste and redundant tests.
• Better clinical decision making by integrating patient information from multiple sources.

Advantages of Electronic Health Records

EHRs and the ability to exchange health information electronically can help you provide higher quality and safer care for patients while creating tangible enhancements for your organization. EHRs help providers better manage care for patients and provide better health care by:

• Providing accurate, up-to-date, and complete information about patients at the point of care
• Enabling quick access to patient records for more coordinated, efficient care
• Securely sharing electronic information with patients and other clinicians
• Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care
• Improving patient and provider interaction and communication, as well as health care convenience
• Enabling safer, more reliable prescribing
• Helping promote legible, complete documentation and accurate, streamlined coding and billing
• Enhancing privacy and security of patient data
• Helping providers improve productivity and work-life balance
• Enabling providers to improve efficiency and meet their business goals
• Reducing costs through decreased paperwork, improved safety, reduced duplication of testing, and improved health.

Meaningful Use

One of the best ways to ensure you take full advantage of the benefits of electronic health records is to achieve meaningful use. By achieving meaningful use, you can reap benefits beyond financial incentives.

Technical features

• Digital formatting enables information to be used and shared over secure networks
• Track care (e.g. prescriptions) and outcomes (e.g. blood pressure)
• Trigger warnings and reminders
• Send and receive orders, reports, and results

Health Information Exchange

• Technical and social framework that enables information to move electronically between organizations
• Reporting to public health
• ePrescribing
• Sharing laboratory results with providers

Standards

• ANSI X12 (EDI) - transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data.
• CEN's TC/251 provides EHR standards in Europe including:
• EN 13606, communication standards for EHR information
• CONTSYS (EN 13940), supports continuity of care record standardization.
• HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
• Continuity of Care Record - ASTM International Continuity of Care Record standard
• DICOM - an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association)
• HL7 - a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems
• ISO - ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures
• xDT - a family of data exchange formats for medical purposes that is used in the German public health system.