An Electronic Health Record (EHR) is a digital version of a patient’s medical history. It is a
longitudinal record of patient health information generated by one or several encounters in any healthcare providing setting. The term is often used interchangeably with EMR (Electronic Medical Record) and CPR (Computer-based Patient Record). It encompasses a full range of data relevant to a patient’s care such as demographics, problems, medications, physician’s observations, vital signs, medical history, immunizations, laboratory data, radiology reports, personal statistics, progress notes, and billing data.
An EHR system integrates data for different purposes. It enables the administrator to utilize the data for billing purposes, the physician to analyze patient diagnostics information and treatment effectiveness, the nurse to report adverse conditions, and the researcher to discover new knowledge.
EHR has several advantages over paper-based systems. Storage and retrieval of data is obviously more efficient using EHRs. It helps to improve quality and convenience of patient care, increase patient participation in the healthcare process, improve accuracy of diagnoses and health outcomes, and improve care coordination. It also reduces cost by eliminating the need for paper and other storage media. It provides the opportunity for research in different disciplines. In 2011, 54% of physicians had adopted an EHR system, and about three-quarters of adopters reported that using an EHR system resulted in enhanced patient care.
History of EHR
The first known medical record can be traced back to the fifth century B.C. when Hippocrates
prescribed two goals for medical records.
- A medical record should accurately reflect the course of disease.
- A medical record should indicate the probable cause of disease.
Modern EHR can provide additional functionalities that could not be performed using paper-based systems. Modern-day EHR first began to appear in the 1960s. Early EHRs were developed due to physicians’ concerns about the increasing complexity and size of medical data. Data retrieval was much faster using digital format. In 1967, Latter Day Saints Hospitals in Utah started using Health Evaluation through Logical Programming (HELP) software. HELP is notable for its pioneering logical decision support features. In 1969, Harvard Medical School developed its own software Computer Stored Ambulatory Record (COASTER) and Duke University began to develop The Medical Record (TMR).
In 1970, Lockheed unveiled the Technicon Medical Information Management System/ Technicon Data System (TDS). It was implemented at El Camion Hospital in California. It came with a groundbreaking Computer Provided Order Entry (CPOE) system. In 1979, Judith Faulkner, a computer programmer established Human Services Computing Inc., which developed the Chronicles data repository. The company later became Epic Systems. It was initially based on a single longitudinal patient record and designed to handle enterprise-wide data from inpatient, ambulatory, and payer environments.
In 1985, The Department of Veterans Affairs launched the automated data processing system, Decentralized Hospital Computer Program (DHCP), which includes extensive clinical and administrative capabilities within its medical facilities. It received the Smithsonian Award for best use of Information Technology in Medicine in 1995. The current variant of DHCP is VistA (Veterans Health Information Systems and Technology Architecture). By providing care to over 8 million veterans operating in 163 hospitals, 800 clinics, and 135 nursing homes, VistA manages one of the largest medical system in the United States.
From 2000 and beyond, EHR software has been increasingly trying to incorporate other functionalities to become an interactive companion for physicians and professionals. In January 2004, President George W. Bush launched an initiative for the widespread adaptation of EHRs within the next 10 years. He said in his State of the Union Address, “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care”.
Components of EHR
The main purpose of EHR is to support clinical care and billing. This also includes other functionalities, such as improving the quality and convenience of patient care, improving the accuracy of diagnoses and health outcomes, improving care coordination and patient participation, improving cost savings, and finally, improving the general health of the population. Most modern EHR systems are designed to integrate data from different components such as administrative, nursing, pharmacy, laboratory, radiology, and physician’ entries, etc.
Electronic records may be generated from any department. Hospitals and clinics may have a number of different ancillary system providers; in that case, these systems are not necessarily integrated to the main EHR system. It is possible that these systems are stand-alone, and different standards of vocabularies have been used. If appropriate interfaces are provided, data from these systems can be incorporated in a consolidated fashion; otherwise a clinician has to open and log into a series of applications to get the complete patient record.
Administrative System Components
Administrative data such as patient registration, admission, discharge, and transfer data are key components of the EHR. It also includes name, demographics, employer history, chief compliant, patient disposition, etc., along with the patient billing information. Social history data such as marital status, home environment, daily routine, dietary patterns, sleep patterns, exercise patterns, tobacco use, alcohol use, drug use and family history data such as personal health history, hereditary diseases, father, mother and sibling(s) health status, age, and cause of death can also be a part of it.
During the registration process, a patient is generally assigned a unique identification key comprising of a numeric or alphanumeric sequence. This key helps to link all the components across different platforms. For example, lab test data can create an electronic record and another record is created from radiology results. Both records will have the same identifier key to represent a single patient. Records of a previous encounter are also pulled up using this key. It is often referred to as the medical record number or master patient index (MPI). Administrative data allows the aggregation of a person’s health information for clinical analysis and research.
Radiology System Components
In hospital radiology departments, radiology information systems (RIS) are used for managing
medical imagery and associated data. RIS is the core database to store, manipulate, and distribute patient radiological data. It uses Current Procedural Terminology (CPT) or International Classification of Diseases (ICD) coding systems to identify procedures and resources. An RIS can generate an entire patient’s imagery history and statistical reports for patients or procedures. Although many hospitals are using RIS, it may or may not be integrated with the central EHR system.
Pharmacy System Components
In hospitals and clinics, the pharmacy department’s responsibility is to maintain the inventory,
prescription management, billing, and dispensing medications. The pharmacy component in EHR will hold the complete medication history of a patient such as drug name, dosage, route, quantity, frequency, start and stop date, prescribed by, allergic reaction to medications, source of medication, etc. Pharmacists serve an important public health role by administering immunizations and must have the capabilities to document these services and share this information with other healthcare providers and public health organizations.
They assure safe and effective medication and supporting patient-centered care. Pharmacies are highly automated in large hospitals. Again, it may be independent of central EHRs. The Food and Drug Administration (FDA) requires all the drugs to be registered and reported using a National Drug Code (NDC). Coding systems used are NDC, SNOMED, and RxNorm.
A clinical document contains the information related to the care and services provided to the
patient. It increases the value of EHR by allowing electronic capture of clinical reports, patient
assessments, and progress reports. A clinical document may include.
- Physician, nurse, and other clinician notes
- Relevant dates and times associated with the document
- The performers of the care described
- Flow sheets (vital signs, input and output, and problems lists)
- Perioperative notes
- Discharge summaries
- Transcription document management
- Medical records abstracts
- Advance directives or living wills
- Durable powers or attorney for healthcare decisions
- Consents (procedural)
- Medical record/chart tracking
- Release of information (including authorizations)
- Staff credentialing/staff qualification and appointments documentations
- Chart deficiency tracking
- Utilization management
- The intended recipient of the information and the time the document was written
- The sources of information contained within the document
Clinical documents are important because documentation is critical for patient care, serves as a legal document, quality reviews, and validates the patient care provided. Well-documented medical records reduce the re-work of claims processing, compliance with CMS (Centers for Medicare and Medicaid Services), Tricare and other payer’s regulations and guidelines, and finally impacts coding, billing, and reimbursement. A clinical document is intended for better communication with the providers.
It helps physicians to demonstrate accountability and may ensure quality care provided to the patient. A clinical document needs to be patient centered, accurate, complete, concise, and timely to serve these purposes.
Electronic health records are the obvious and inevitable future of patient care in hospitals and medical practices. This chapter discusses several aspects of the EHRs. EHR systems are gaining nationwide popularity in the United States recently due to “Meaningful use legislation and reimbursement. It is being widely installed in hospitals, academic medical centers,” and outpatient clinics throughout the nation. Besides healthcare benefits like improved patient care, safety and reduced costs, it creates great opportunity for clinical and translational research.
Widespread adoption of EHRs can foster the improvement of quality in healthcare services, safety and efficiency, and most importantly, public health. Having great potential for benefits, successful deployment of EHRs has several challenges to overcome. There are notable limitations of the use of EHR data in research purposes. In the era of technology, the necessary laws lag far behind. While other developed countries have showed widespread adoption, in the United States, the overall adoption is considerably low. Bigger Government initiatives and enhanced standardization today can lead to a brighter healthcare tomorrow.