Electronic Health Records 101

More than a database

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The electronic health record (EHR) is an electronic record of patient health information generated by encounters in any health care setting. EHRs have grown in use recently, with 71.8% of office-based physicians reporting using any type of EHR system in 2012, compared to 34.8% in 2007.

Data in the EHR

The EHR can document a complete record of a clinical patient encounter. The information in the EHR is created, managed, and viewed by authorized health care providers, staff, and other entities across different health care settings and locations.

Major types of information in the EHR include:

  • Demographics (e.g. age, date of birth, gender)
  • Contact information (e.g. phone number, address)
  • Past medical history
  • Active medical problems
  • Immunizations
  • Allergies
  • Medications
  • Vital signs
  • Results from laboratory and radiology tests
  • Progress notes (narrative description of the patient's status, diagnoses, tests, and treatments)
  • Administrative and financial documents

Accessing and recording information

The most basic function of an EHR is to allow clinicians to create, access, and share the information and data necessary to take care of patients. Consider the following example of how an EHR might be used when a patient visits her primary care physician for a routine check up. The medical assistant measures the patient’s vital signs, updates the list of allergies and medications, and enters all the information into the EHR for the doctor to review. The doctor also reviews the patient’s active medical problems, medications, allergies, details from last year’s visit, as well as information recorded by the patient’s cardiologist two months ago.

Furthermore, the doctor reads the discharge summary sent by a nearby hospital describing what happened when the patient was hospitalized for pneumonia, including test results and progress notes from other doctors. During or after the visit, the doctor enters information into the patient record in the form of a progress note.

Compared to paper records, a basic advantage of the EHR is that a patient’s information is not confined to specific geographic locations. Clinicians at different locations of the same health care organization (e.g. different floors of a hospital, or different sites of large medical practice) can use the EHR to access patient records. However, EHRs maintained by separate health care organizations often do not share information

When fully implemented, the EHR is more than just a passive, digital record. The EHR is also a software platform that acts as the foundation for other tools involved in health care delivery. The following sections describe how an EHR supports computerized physician order entry, clinical decision support, and patient registries.

Computerized physician order entry

Computerized physician order entry is the process of entering orders for medications, lab/radiology tests, and referrals electronically into the EHR. Continuing the example from above, the doctor uses the EHR to send an electronic prescription to renew the patient’s current medications and start a new prescription.

The doctor also refers her to a gastroenterologist for a screening colonoscopy.

Clinical decision support

Clinical decision support systems are interactive tools integrated into EHRs to provide health care providers with timely, customized recommendations. Clinical decision support uses information from the EHR along with evidence-based guidelines to generate specific recommendations that are relevant to the patient’s situation. For example, when the doctor above entered the electronic prescription for a new medication, the clinical decision support system advised that certain doses should be avoided due the patient’s chronic kidney disease.

Patient registry

A patient registry is an organized system that uses observational methods to collect data for assessment of outcomes in a defined patient population. Certain registries rely on EHRs for information about clinical encounters.


Office of the National Coordinator for Health Information Technology. Learn EHR Basics. Accessed on May 26, 2014.

Hsiao C-J et al. Trends in electronic health record system use among office-based physicians: United States, 2007–2012. National health statistics reports; no 75. Hyattsville, MD: National Center for Health Statistics. 2014. Accessed on May 26, 2014.

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