EHR (Electronic Health Record)

EHR

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 -->

What are the Components of Electronic Health Records?

Electronic health records include a variety of information on the patient’s health history, treatment background, and ongoing documentation, including:

  • Patient demographics
  • Patient’s medical history
  • Allergies
  • Immunization history
  • Vital signs
  • Diagnoses
  • Treatment plans
  • Medications
  • Laboratory and test results
  • Imaging (X-rays, MRI scans, CT scans, etc.)
  • Administrative and billing data
  • Clinicians’ progress notes

What’s the Difference Between an Electronic Health Record and an Electronic Medical Record?

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.

EHR Benefits

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

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:

  • Integration and compatibility with existing practice management or other software
  • The size and scale of the practice or organization
  • The need for an EHR system designed for a clinical specialty
  • Security and compliance
  • Mobile accessibility
  • Features like patient portals and e-prescribing

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

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.