Overview
The electronic health record (EHR) is the focus of efforts throughout the health industry to employ the most comprehensive information available to best inform the care delivery process. The definition recognizes that health-related information about a patient is available in multiple locations and systems and that, if presented through a common and user-friendly interface, this information can improve the ability of clinical personnel to support the best possible diagnosis, treatment, and health management decisions for and with an individual.
The ability to aggregate comprehensive information, whether physically within one record or virtually from records in multiple locations, is currently limited. Technical standards and common vocabularies for medical terms have yet to be agreed upon let alone implemented for many different types of data originating from many diverse sources. The potential for digitizing information and thus making it available to all involved in health care will improve over time, in step with progress in the interoperability of information and the increased adoption of EHRs within the delivery system.
In the past, a person’s medical history was recorded primarily to document how clinicians in a single care organization treated that person’s health needs during a clinical encounter. EHRs will help health care providers move to a more efficient way of organizing and sharing information beyond the scope of one organization or single encounter. EHRs take advantage of advances in computer performance and electronic communication to present a patient-focused view of an individual’s health information recorded by various provider facilities—such as physician offices, hospitals, long-term care facilities, behavioral health centers, home-based care, laboratories and pharmacies—and authorized clinicians, such as physicians, nurses, social workers and others involved in an individual’s care.
EHRs will allow the recorded narratives, newly added observations and test results for a patient to be brought together from multiple settings and locations of care providers into one health record. In addition, information from administrative sources may also be included, such as: claims data from health plans; formulary and medication data from pharmacy benefit managers, and demographic data. It is expected that the information contained in an EHR be maintained in a secure manner that protects the confidentiality of the individual’s information.
The scope of this definition is limited to the content and characteristics of the underlying record, not on the systems that perform functions enabling data in the record to be used for various purposes. Thus it is different from, and cannot be equated with, establishing detailed functional standards or criteria.
Electronic Health Record (EHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.
Understanding an EHR
An EHR is patient-focused in that it is not limited by what a single provider organization is able to accumulate on behalf of a patient under its care. Through the capabilities of interoperability, an EHR becomes an authorized means to access information from whatever sources have chronicled the health care experience of a patient over time. The boundaries of an EHR are built not around the organization documenting the information but around the patient and his or her health-related information. Though it is patient-focused, it is managed and used primarily by authorized care providers, as well as by members of their staff who have a need to access the EHR to support the process of care.
Cradle to grave. As the information in an EHR is drawn from multiple organizations, the envisioned goal is for it to be a comprehensive, longitudinal record of an individual’s pertinent health history. Due to the depth and breadth of data, an EHR thus offers a perspective on changes in health and medical conditions over time.
Information richness. Examples of information that can be contributed to and accessed in an interoperable EHR include:
- Past and current clinical information incorporated from all organizations that have been engaged in an individual’s care or health maintenance.
- Administrative information pertinent to making clinical judgments and cost-sensitive decisions. One example is the multiple formularies used to select medications based on a patient’s insurance benefits.
- Population-based data from sources such as disease registries and initiatives to detect disease outbreaks.
- Information that can be interjected into a clinical situation or used to interpret data on an individual to support and improve clinical decisions. Examples include alerts about harmful interactions of one drug with another, and formulas for medication dosing based on patient-specific conditions such as diabetes and factors such as age and weight.
- Information on evidence-based medicine, scientific research studies, or environmental situations.
- Information from remote monitoring devices, which capture real-time data on vital signs, cardiac or respiratory status, lab test values, etc.
- Information provided by PHRs, including patient-entered documentation, to supplement and enhance knowledge of a person’s health status and initiative.