Although a type of electronic health record (EHR) was first introduced in the 1970s, it was not until recently that EHRs have become widely used. Today, numerous health care systems have electronic health records at their patients’ fingertips, allowing individuals to see their health histories at a glance and take a larger role in their own health care. The electronic health record gives patients and providers alike a safe and secure way to store all of a patient’s records online where they can be easily accessed at any time.
Electronic Health Record
As technology becomes more intertwined with everyday life each passing year, it is increasingly moving into the health care arena. The electronic health record offers health care facilities a unique way to keep track of patient records, allowing them to move past the paper records that have caused a myriad of problems for so many years.
By definition, an electronic health record (EHR) is a digital or electronic version of a typical patient medical chart that includes all facets of a patient’s overall health and follows them through the medical system for years.
Electronic health records contain all pertinent health information, including, but not limited to:
- Lists of medical issues
- Past surgeries
- Current prescription medications
- Most recent vital signs
- All laboratory values
- Radiologic and pathologic reports
- Provider progress notes
- Hospital discharge paperwork
- Patient demographic information.
It also offers patients a portal to communicate with their providers, contribute applicable health care information, and manage their own health care for improved disease prevention.
Electronic health records can also share information with many other medical providers, creating a seamless process designed to provide patients' best possible health outcomes.
For example, a physician can use the EHR to communicate with other team members, specialists, pharmacists, and laboratory personnel. When needed, an EHR can also be shared with workplaces and schools for clinical reasons.
What Do EHRs Do?
Unlike the bulky and confusing paper charts of years past that only a single person could view at a time, electronic health records are living documents that move and grow with a patient. It represents their general health and helps clinicians create the best outcomes for the patient. Today, these electronic records are seen as vital components to health care as a whole because of the positive outcomes they provide.
Provide Access to Health Care Information
First, the EHR gives physicians, other clinicians, and patients themselves access to the complete health care record. As mentioned, this includes all relevant past and current medical histories, important demographic data that can affect the type of care given, and reports from all clinicians who have cared for the patient. In addition, clinicians can use pieces of this record to make the best possible decisions for their patients and to provide outcome-based care.
Today, providers have more patients than ever to see, but documentation remains a key component of high-quality health care. EHRs help to speed up and simplify this process so providers can continue to provide the best care possible. Because EHRs are created with a digital interface, they can be shared with providers at other medical facilities so that each clinician will have a complete and accurate picture of the patient.
Keep All Patient Information in One Place
Second, with the EHR, health care facilities no longer have to worry that a piece of information could go missing from a patient’s chart. Instead, this digital record is stored in a single file on a server or in the cloud so that any authorized user can access it at any time. The information in the EHR is instantly available for making in-the-moment decisions that are backed by solid and accurate information. Providers can instantly see information about allergies, concurrent diagnoses, most recent immunization dates, and much more to make decisions that can most benefit the patient’s health. All information is well-organized and easily accessible. In fact, because the EHR can be shared with other health care systems, it can follow the patient around the country and to other doctors throughout their entire life.
Who Uses EHRs?
Electronic health records are always safely protected on servers or in the cloud so that only authorized users can access sensitive patient data. However, those who have been cleared to view and make changes to the record can easily and instantly find the information they need. The two key groups of people who usually use EHRs are health care providers and patients. Biometric and two-step access systems are becoming more popular to prevent misuse of this data.
1. Health Care Providers
EHRs were initially designed for health care providers to replace bulky and problematic paper charts. Physicians use this electronic chart to view past patient histories, medication records, and radiologic reports. They can create new prescriptions, refill old prescriptions, order and review laboratory or radiology studies, and answer patient messages.
They can also communicate with other providers who are taking part in the patient’s care plan. Of course, most physicians today do most of their patient documentation on the EHR. In addition, provider teams can work with billing statements and patient payments directly through the EHR, often completely removing the need for paper bills.
Even though the EHR may have been originally designed with the patient care provider in mind, patients today can greatly benefit from access to this record. Patients most frequently use the EHR for communicating with their physicians, such as asking questions about new health problems or medication instructions.
Depending on the system, patients may also be able to view their past visit summaries, immediately view their laboratory results when they become available, easily request medication refills, and pay their bills. Some sites also include health care education documents to help patients take more active roles in their health care.
Why Adopt an Electronic Health Record?
An electronic health record can bring a wide range of benefits to health care organizations of all sizes as well as to patients. These benefits range from organizational advantages, such as cost savings and improved patient satisfaction scores, to clinical benefits, including decreased medical errors and improved patient care outcomes. In general, doctors are able to provide a higher level of care to each of their patients while being able to see more patients in a shorter amount of time once they become used to the EHR system.
Well-Linked Health Care Information
The primary reason why many health care organizations adopt EHRs is to link their patient care services throughout the entire system. All information is readily accessible at any computer terminal, including those at clinic offices, bedsides, and nurses’ stations. These links also extend beyond the primary health care system to other providers caring for the patient. This ensures better patient care outcomes, as all clinicians collaborate to provide the best possible care.
Medical Error Reduction
Over time, it has also been noted that EHR usage can reduce unintentional medical errors. EHRs provide another method of checking medications and laboratory values and can clue clinicians into possible interactions, dangerous values, and emergency health information that they must address immediately. As a result, unintentional medical errors are also reduced when clinicians do not have to worry that pieces of the paper record have been lost.
Improved Efficiency in Health Care Settings
Once learned and implemented throughout the entire health care system, EHRs can actually speed up work for clinicians while improving their efficiency and productivity. The main reason for this is that the clinician no longer has to wait for a paper chart to be sent to them but can instead access the entire chart wherever they are. Clinicians can also save time by not having to decode sloppily written orders, reducing the amount of paperwork they have to do, speeding up the prescribing process, and using speech recognition software already built into the system. This also speeds up the billing process as codes can be automatically generated for insurance claims.
Improved Patient Care Coordination
Many people move around the country these days, and even those who do not move frequently may find that they change health care systems in their own communities over the years. The EHR's benefit is that the patient’s complete medical record can follow the patient wherever they travel. This ensures that no useful health care information is lost over the years.
Improved Patient Outcomes
When a patient’s entire medical history follows them wherever they go, they can expect better medical outcomes because clinicians can better treat and prevent various injuries and diseases. They will not have to worry about unnecessarily repeated procedures or medications that could interact with each other. In addition, the chart is always kept current.
No More Paper Charts
In years past, large storage facilities had to be dedicated to keeping paper records safe, and huge amounts of money were poured into administrative tasks related to maintaining these charts. In some cases, vital patient information was lost. Only one clinician could view the paper chart at any one time. The EHR eliminates all of these problems by safely storing all records in a digital format that is viewable anywhere. Illegibility and other manners of lost or unintelligible information have been erased utilizing the computer and EHR servers.
Nearly every health care system is looking for a way to save money, and adopting an EHR is a smart route to take. Time savings also equals money savings as staff can work quickly and care for more patients in a single day. Plus, hospitals no longer have to pay to maintain storage facilities or pay administrative personnel for retrieving paper charts. A 2009 government stimulus package associated with the Health Information Technology for Economic and Clinical Health Act approved various reimbursements for facilities implementing EHRs. Medicaid also enacted policies that required the usage of EHRs for reimbursement.
Differences Between EMRs and EHRs
EHRs are frequently confused with another similar record keeper, the electronic medical record (EMR). While EHRs and EMRs are similar in that they provide digital records of key health care information, they have specific differences that set them apart.
EHRs Include All Health Data
As mentioned, EHRs contain every last bit of health data from all clinicians and can follow the patient from facility to facility over his lifetime. However, EMRs are specific to a single health care facility and is often not as accessible to the patient. EMRs do not follow the patient if they move across the country or switch to a different healthcare organization.
Other Key Differences
Because the EMR is more like a digitalized version of a simple patient chart than the EHR is, it is typically used by health care providers alone as they make patient diagnoses and prescribe treatments. The EHR provides a more complete set of information that travels with the patient to other specialists.
Keep in mind that EHRs can meet certain standards under the Certified EHR Technology (CEHRT) program and may be eligible for reimbursements through certain incentive programs. However, EMRs are never certified and do not meet specific standards across the board.
While EMRs are mainly used for diagnostics and treatments, EHRs include a wealth of other information that can help physicians make meaningful decisions for their patients. Evidence-based tools help direct appropriate treatments throughout patients’ lifespans. Patient education can also be provided via the EHR and allows for more information about a health condition to be shared with the patient.
Electronic health records continue to impact health care significantly.
Health care organizations that adopt them find that they can improve patient outcomes, increase patient satisfaction, and save money. Without the irritations of older paper charts, clinicians can now provide more meaningful care that is based on past health information without a great deal of wasted time. The usage of these tools can save money, energy, and the patient's lives.