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Electronic Health Record: Digital Record of Health Information

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An electronic health record is a systematized collection of an individual's health records stored electronically in a digital format. Read on to know more.

Medically reviewed by

Dr. Mohammad Rajja

Published At December 20, 2022
Reviewed AtFebruary 2, 2023

Introduction:

An electronic health record (EHR) collects the patient's medical records generated during any clinical encounter or event. These records can be accessed and shared across different healthcare systems. The electronic health record contains the results of the clinical and administrative meetings between the provider (nurse, physician, or others) and the patient. The EHR includes various components making a secure connection between patients, clinics, medical practices, imaging centers, hospitals, laboratories, and pharmacies in a standardized format.

What Is an Electronic Health Record?

An electronic health record is a real-time, patient-centered record that enables an individual's health information to be available and instantly accessible securely across authorized healthcare users.

  • It contains medical history, current health status, allergies, diagnoses, treatment plans, medication regimen, demographics, immunization chart, diagnostic test results like radiology imaging, laboratory test reports, hospitalization records and discharge summary, and billing information.

  • The electronic health record helps to automate and streamline providers' workflow.

  • The electronic health record can be accessed and shared across various healthcare organizations that an individual is associated with.

What Is the Objective of Electronic Health Records?

The objective of an electronic health record is to introduce a uniform, standard-based system for creating and maintaining the patient's health record by healthcare providers, which can be accessed and shared across the healthcare system.

What Is the Importance of Electronic Health Records?

  • Electronic health records have long-term clinical relevance.

  • It provides a structured overview of an individual's health.

  • It is an evidence-based tool that contains an individual's health file.

  • It provides a brief summary of the person's health status and health-related issues.

  • It records every clinical encounter of an individual from his birth to death.

  • It acts as a source in diagnosis and treatment planning.

What Are the Benefits of Electronic Health Records on Patient Care?

  1. It provides access to an individual's health record 24/7.

  2. It improves quality care.

  3. It enables clinical efficiency.

  4. It optimizes quality performance.

  5. It provides support to individuals.

  6. It facilitates improved coordinated care.

  7. It prevents physicians from burnout. It helps in saving time by automating manual processes like charting and prescribing medications.

  8. It protects against data breaches and ensures HIPAA compliance with increased personal health information security measures.

  9. It acts as a communication channel between the health care provider and individuals.

  10. It enables improved diagnostics and patient outcomes.

  11. It signifies improved patient care.

  12. It helps to achieve practice efficiencies and cost savings.

  13. It increases patient participation.

  14. It acts as an evidence-based health file.

  15. It strengthens the relationship between the provider and the individual.

  16. It reduces the incidence of medical errors by improving the accuracy and clarity of medical records.

  17. It reduces the incidence of missed data and lost medical files.

  18. It helps avoid duplicating tests and faster and more accurate diagnosis and treatment planning.

  19. Digital health records are easy to read and store.

  20. Billing information enables faster and more accurate insurance.

  21. It acts as a tool for preventative health.

  22. Electronic health records will facilitate the measurement of many important outcomes for researchers.

  23. It generates reports on practice efficiency and compliance with government programs and policies.

  24. Electronic health records will foster the growth of evidence-based practice, reduce medical errors and enforce the documentation of diagnosis, evaluation, treatment, and management of an individual's medical condition.

What Are the Components of Electronic Health Records?

  • Identification Information: Includes name, date of birth, age, and gender.

  • Past Medical and Surgery History: Includes allergy, present and past diagnosis, medical care, and treatments.

  • Medical Information: Medication given, allergy to any medication, dosage and schedule, type of medication taken, current medication regimen, and also whether it is a prescription medication, herbal remedies, illegal substances, or OTC medication.

  • Family History: Family medical history enables one to diagnose a medical condition and to be cautious of hereditary components.

  • Personal History: It includes socioeconomic history and occupational history.

  • Treatment History: It includes chief complaints, history of present illness, vital signs, review of systems, physical examination, medical history, family history, immunization history, habits like diet, physical activity, smoking, alcohol intake, or illegal drug use, developmental history, diagnostic information, and treatment plan.

  • Medical Directives: These outline an individual's or his family's directions regarding what they want or do not want in their medical care. It majorly includes the do not resuscitate order and their will.

  • Consent Forms: Consent for diagnosis, recovery chances, awareness of the benefits and risks of the treatment, success probability if the treatment is taken, treatment including medications, medical procedures, and surgeries.

  • Progress Notes: These are the notes made by the physicians if any changes or new information arises during the course of the treatment.

  • Financial Information: It includes the subscriber’s name, billing information, policy number, details of the insurance payer, details of the employer of the responsible party, and the relationship of the individual to the one insured.

What Are the Disadvantages of Electronic Health Records?

  • If the electronic health records are not updated, it leads to misinformation and incorrect diagnosis and treatment planning.

  • Entering an individual's medical information into the electronic health record is time-consuming, involves infrastructure, and costs money.

  • Inconsistency and inefficiency: If the electronic health record is not updated, it leads to inaccuracy in diagnosis and treatment planning.

  • HIPAA violations can hamper the violation of care.

  • Accessibility to computers and the internet is not possible all the time.

What Is the Difference Between Electronic Health Records and Electronic Medical Records?

Electronic medical records are digital versions of paper charts and are maintained at the doctor's office, mainly used in and accessed by a single provider and practice. The electronic health record is the digital record of health information designed to be accessed and shared across the healthcare system and different health organizations the individual is associated with.

Conclusion:

An electronic health record is a set of predefined standards for information that facilitates the capture, storage, retrieval, exchange, and analytics that, including images, clinical codes, and data, is imperative. In a nutshell, an electronic health record is a digital record of health information. The electronic health record includes many components linking patients, practices, clinics, imaging centers, hospitals, health plans, laboratories, and pharmacies over the digital platform in a confidential, secure and standardized, and structured format.

Frequently Asked Questions

1.

What Are the Various Uses of Electronic Medical Records (EMRS)?

Electronic medical records have several uses, such as - 
- Help document the entire course of treatment and its results. 
- Stores accurate information about the patient.
- Allows physicians to record the history of the patient. 
- Can be used for insurance claims as well. 
- Can be used for writing prescriptions and easy communication within the hospital.

2.

How Can Documentation in Electronic Medical Records Be Improved?

The various ways in which documentation of electronic medical records be improved are as follows - 
- Employing the use of legitimate systems. 
- Spending rescue to train people efficiently. 
- All entries should be clear, understandable, and coded appropriately.
- All entries should meet regulatory standards and licensure. 

3.

What Are the Disadvantages of Electronic Health Records?

Although they have a lot of advantages, electronic health records do have a few disadvantages, such as -
- They require immense funds, especially for their maintenance. 
- Due to any system or operational failure, the hospitals may require to halt their functioning, resulting in immense losses. 
- It requires time and funds for training.

4.

What Are Electronic Health Records?

A standard patient medical chart that contains all aspects of a patient's general health and tracks them across the healthcare system for years is called an electronic health record (EHR).
All relevant health data is included in electronic health records; for example -
- All medical conditions.
- Past operations.
- Present-day prescription drugs.
- All vitals. 
- Every laboratory finding.
- Reports on the pathology and radiology.
- Notes on provider progress.
- Forms for hospital discharge.
- Data on the patient's demographics.

5.

Can Electronic Medical Records Be Destroyed?

Yes, they can be destroyed. After a certain period of time, medical records, both paper and electronic, should be destroyed. Measures should be taken to ensure that electronic medical records are destroyed in a manner that ensures that the information is not recognizable, retrievable, or can be reconstructed or practically read.

6.

How Do Electronic Health Records Improve Patient Care?

Electronic health records help improve patient care in the following manner - 
- They help store all medical data in one place. 
- Data, if lost, can be easily retrieved. 
- They help eliminate medical errors. 
- They help divert time and resources to actual patient care instead of using them in paperwork and documentation. 
- They can also be used for insurance purposes. 
- They help doctors monitor and track patients' health at any given point. 

7.

What Are the Various Entities That Electronic Health Records Contain?

The various entities of electronic health care records are as follows - 
- Medical history.
- Past operations.
- Immunizations.
- Present-day prescription drugs.
- All vitals. 
- History of past diagnoses. 
- History of allergies. 
- Every laboratory finding.
- Reports on pathology and radiology.
- Notes on provider progress.
- Forms for hospital discharge.
- Data on the patient's demographics.

8.

Can Electronic Health Records Be Used for Decision-Making and Problem-Solving?

Yes, electronic health records can be used to improve decision-making and problems solving. This is primarily because - 
- The records act as an aggregate of all medical information of the patient, thereby making it easier to analyze, communicate and tailor a treatment plan. 
- They support the diagnostic aspect of a treatment plan. 
- They provide a platform to monitor the progress following treatment and medications conveniently. 

9.

What Are the Benefits and Risks of Electronic Health Records?

Electronic health records have innumerable benefits, such as -
- Help provide access to healthcare information.
- Help keep all patient data secure in one place. 
- Help reduce documentation errors. 
- Help reduce medical errors. 
- Enable better file organization, storage, and documentation.
- Enable doctors to track progress and response to treatment.  
- However, one of the major risks associated with such records is that if the system fails, then the entire workflow can be disrupted. 

10.

Can Electronic Medical Records Be Affected by Technology?

It is because of technology and electronic health records doctors are able to provide optimal treatment to patients. Things which were not possible with simple paper records, such as viewing, monitoring, and printing vitals at any given time of the day, are now possible with electronic health records.  In the future, with more improvisations and newer technology, electronic health records can possibly see more changes, which will only benefit the healthcare industry in all possible ways. 

11.

Can Electronic Health Records Be Used in the Future?

With the rise in telehealth companies and cloud-based healthcare systems, it is safe to say that electronic health records will definitely be used in the future as well. In fact, it is because of the existence of such records several healthcare platforms have opened up, thereby extending healthcare to all corners of the world in the most convenient manner. 
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Dr. Mohammad Rajja
Dr. Mohammad Rajja

General Practitioner

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