An electronic health record (EHR) is a digital version of a patient’s health chart that contains the patient’s medical and treatment history. The Centers for Medicare and Medicaid Services (CMS) and the Health and Human Services (HHS) Office of the National Coordinator for Health Information Technology (ONS) promote the use of electronic health records to give patients more access to and control over their health records, support information sharing among providers, and improve the quality of patient care by providing clinicians with access to more comprehensive information about a patient’s medical history and treatments. Jump to resource links -->
Electronic health records include a variety of information on the patient’s health history, treatment background, and ongoing documentation, including:
Electronic health record and electronic medical record (EMR) are two terms often used interchangeably; however, there are significant differences. EMRs came along first. A digital representation of the traditional paper patient chart, EMRs contain patients’ medical and treatment histories for a single practice, allowing providers to collect clinical data and track data over time, but they’re not easily shared among providers or organizations.
EHRs, on the other hand, aim to go beyond the scope of EMRs to include a broader picture of a patient’s history and care and are designed to be easily shared among providers and organizations. The hallmark of EHRs is that they’re patient-centered, rather than provider-centered.
Real-time, patient-centered records, EHRs can be accessed instantly and securely by authorized users, allowing clinicians to readily access a patient’s comprehensive health history to inform clinical decision-making. EHRs allow authorized providers from different organizations to create and manage health information, allowing the patient’s health and treatment history to be shared across multiple providers and organizations.
Because they’re shared among multiple providers and organizations, EHRs provide a more comprehensive record including information from all clinicians involved in a patient’s care. They also offer access to evidence-based tools that clinicians can access at the point of care to inform their decision-making regarding the patient’s care, streamlining clinicians’ workflows. By providing real-time access to more complete, organized, and accurate patient information, EHRs help to reduce medical errors, treatment delays, and the duplication of tests.
EHR systems are the software foundation for electronic health records. EHR systems can be deployed locally or in the cloud. There are many considerations to weigh when selecting EHR systems, such as:
For instance, an expanding practice may opt for a cloud-based EHR system that can scale with their practice as it grows. Cloud-based EHR systems also are more readily accessible from mobile devices such as tablets and smartphones, which is an added convenience for providers.
EHR implementation is a multi-disciplinary approach requiring careful planning and management pre-, during, and post-implementation. EHR implementation requires preparing the EHR system, addressing privacy and security compliance, planning and developing clinical practice workflows, and training both clinical and administrative staff.
Organizations must ensure that the chosen EHR system meets meaningful use requirements as well as the required criteria for use in Medicare and Medicaid. EHR implementation must also consider interoperability; in fact, the Center for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) require EHR software vendors to attest that they have not knowingly implemented any measures that would restrict interoperability, a requirement that aims to restrict information-blocking.
Interoperability is crucial to accessing patient data for proactive care delivery and better outcomes. EHRs and other Health IT (HIT) systems must be able to communicate with each other to support accurate, efficient, and meaningful exchange of clinical data.
The EHR has become one of the most important tools in the healthcare professional toolbox by putting data and analytics and the fingertips of providers. Here are 5 more ways that EHRs help improve patient outcomes, ease provider strain, and lower the cost of healthcare.
Dave Levin, MD
Healthcare is creating mountains of data every single day. However, much of this data is isolated in data silos or formatted in non-standard systems. To effectively leverage this incredible resource, we provide four best practices for EHR data integration that organizations can use to be on the cutting of health IT and advanced analytics.
Dave Levin, MD
With advances in healthcare technology, what does the future hold for electronic health records (EHRs)? Our 26 health IT experts break it down.
The Future of Electronic Health Records (According to 26 Healthcare Pros & Health IT Experts)