Electronic Health Records By Michael Rucker, PhD, MBA | Reviewed by Richard N. Fogoros, MD Updated September 07, 2016 Print Electronic health records (EHRs) and electronic medical records (EMRs) are an advantage of modern health information technology. Although the two terms, EHRs and EMRs, are often used interchangeably, EHRs are chronologically more recent and attempt to include more data than EMRs. EHRs contain information from all the clinicians involved in a patient’s care and are purposefully built to share this information. Electronic records are being increasingly adopted across the United States, replacing the often antiquated and unreliable paper systems that still exist in many hospitals. This is making our health care safer and more efficient. It is not just hospitals making the switch; doctor’s offices, different health care facilitates and insurance companies are making the switch to electronic data-keeping. This new, data-driven ecosystem is connecting health providers and expanding patient’s possibilities. List Complete Medical Record in 6 Basic Parts List 6 Terms Related to the Electronic Health Record Emergency situations, such as accidents, natural disasters and terrorist attacks, are a particularly poignant reminder of the importance of patient data accessibility. If medical records are instantly available—no matter the locale or patient’s condition—the outcomes of treatment can be maximized.EHRs and EMRs are also invaluable in everyday medical situations. Instead of relying on patient’s self-reporting their medical history, doctors who use EHRs now only need the patient’s identifying information (such as name and date of birth) to access his or her entire medical history. This makes the screening process not only quicker, but also safer and more comprehensive. The U.S. government is actively encouraging the use of electronic records by offering incentive programs. If health care providers can prove they are using EHRs and are compliant with a set of rules known as Meaningful Use, these providers are entitled to a partial reimbursement of their investment. The number of health care providers using electronic health records is continuously on the rise, bringing us the reality of an interoperable health system closer to reality.Benefits of EHRsSome of the benefits of digital health records include:Information gathered by primary care providers can be shared by emergency departments. For example, if a person is allergic to a certain drug, this lifesaving alert is passed on even if the patient is unconscious.There is a record of recently run medical tests, so unnecessary duplication can be avoided.Hospital notes, discharge plans and follow-up instructions are readily available, which makes transition from one setting to another smoother.Users can log on to their own records and access their medical information. List Using the SOAP Format With the EHR List Benefits of Converting to Electronic Medical Records Functions of the EMR/EHR Systems EHRs contain basic information like your name, contact numbers, medical history, information about medication and allergies, information about current medical issues, test results and progress notes, as well as administrative and financial documents. Digital records bring all your information together and allow different health professionals to share and exchange this information. For instance, your general practitioner can read your hospital discharge summary, reports from specialists and recent test results by simply accessing your EHR online.In today’s digital era, EHRs should encompass four functions: electronic prescribing, electronic test ordering, reporting of test results and keeping physicians' notes. However, it is important to note that many current EHRs do not always share information. Portability and interoperability have been recognized as current issues, and more work is required to build a better-coordinated health care system. A shared, nationwide interoperability roadmap has been widely adopted, which lays out milestones that various public and private stakeholders are aiming to achieve. These ongoing efforts include improving technical standards, shifting and allying payment policies, coordinating policies and business practices, and allying privacy and security standards. The current roadmap is considered a living document, and new versions are developed based on experience and feedback.Patient Access and Personal Health Records (PHR)Many health providers now offer electronic tools. These tools allow us to access our health data and get involved in our own recordkeeping process. This allows us to address any gaps or mistakes that might appear in our records. When we get actively involved, information sharing becomes easier, making us equal partners in the health care process.Patient portals are playing a significant role in improving our health care experience. Modern advances in digital health give patients access to EHRs and facilitate different aspects of personal health care management, including scheduling appointments, requesting medication refills and improving the accuracy of medical records. Article The Growing Importance of Health Data Interoperability Article Epic EHR Problems Encountered Personal health records or personal medical records (PMR) are distinct from EHRs to the extent that you can control them (rather than being exclusive to your medical provider). They are available to you and can be stored in different ways, for example, downloaded to your computer hard drive or stored in the cloud.Meaningful UseMeaningful Use is a set of rules and objectives that were set to make sure EHRs are implemented in a meaningful way that enables the five pillars of health. Supported by the Health Information Technology for Economic and Clinical (HITECH) Act, Meaningful Use includes using health information technology to improve the quality of health care, reduce health disparities, engage patients (and their families), coordinate health care, and ensure privacy and security of patient information. The goal of meaningful use is to improve population health, increase transparency, empower patients and provide more robust research data.Transition to Meaningful Use was planned as a staged process, with three main stages unfolding over a period of 5 years. The rules for stage 3 — the final stage that aims to improve health outcomes — were released in October 2015 by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC). If health providers can meet the list of meaningful use objectives, they receive a reimbursement.Clinical Decision SupportClinical decision support systems (CDSS) are software systems that were some of the first applications of health tech. They are interactive applications that assist physicians and other health professionals in making evidence-based clinical decisions and improving treatment outcomes.These systems can serve as reminders, diagnostic systems, drug prescribing systems and disease management tools, and can also be integrated into the EHRs. Patient information is combined with evidence-based guidelines to provide the patient with optimal recommendations and treatment. EHRs can connect multiple sources of information and generate predictive algorithms to assist treatment. In diabetes care, for example, EHRs combined with clinical algorithms showed to be superior to standard computer programs when interpreting patient information and guiding care. CDSS models rely on data from live sample groups and connect different sources of information. This makes them a viable diagnostic tool.CDSS can be particularly useful in primary care, where doctors who are not specialized in all areas of medicine encounter patients with varied symptoms who require prompt diagnosing and management plans. Diagnostic CDSS systems cover different areas of medicine, including mental health, cardiac ailments and abdominal illnesses.Privacy and Security of Digital Record KeepingThere are many policies and procedures in place to ensure the protection of data that are stored electronically. A culture of privacy and security is supported and valued, and cybersecurity is a priority in settings where electronic medical records are used.The Health Insurance Portability Accountability Act (HIPAA) was passed in 1996 to protect patients’ records and rights. It stipulates how, and with whom, patient information can be shared.However, there has been a proliferation of digital health devices and technologies that collect health data since the HIPPA was passed (e.g. wearables), so most are not regulated by this legislation. This makes ongoing revisions and oversight necessary and in the interest of our privacy and security.We have a vested interest in making sure our medical records are being handled correctly, as well as stored and shared correctly. Similar to our credit reports, it is wise to monitor our medical information for accuracy and reasons of prudence. HIPAA specifies that accessing and obtaining our health information for our own purposes is a right, not a privilege. This includes accessing an electronic copy of our health information contained in any electronic health record.