An Overview of Electronic Health Records

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.

The U.S. government is actively encouraging the use of electronic records by offering incentive programs. If healthcare 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 the investment they put forth to make that happen.

The number of healthcare providers using electronic health records is continuously on the rise, bringing an interoperable health system closer to reality.

Benefits of EHRs

It is not just hospitals making the switch; doctor’s offices, different healthcare facilities, and insurance companies are doing so as well. This new, data-driven ecosystem is replacing often antiquated and unreliable paper systems, connecting health providers and expanding patient’s possibilities, and making health care safer and more efficient overall.

EHRs and EMRs are 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 their entire medical history. This makes the screening process not only quicker, but also safer and more comprehensive.

Other 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 the transition from one setting to another smoother.
  • Users can log on to their own records and access their medical information.

Emergency situations, such as accidents, natural disasters, and mass shootings, 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.

Functions of EMR/EHR Systems

EHRs contain basic data like your name, contact information, medical history, medications you're taking, allergies you have, current medical issues, test results and progress notes, as well as administrative and financial documents.

Digital records bring all of this together and allow different health professionals to reference, add, and exchange information. In today’s digital era, EHRs should perform four functions:

  • Electronic prescribing
  • Electronic test ordering
  • Reporting of test results
  • Keeping physicians' notes

For instance, your general practitioner should be able to read your hospital discharge summary, reports from specialists, and recent test results by simply accessing your EHR online.

That said, it is important to note that many current EHRs do not always share information. 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.

Meaningful Use

Meaningful use is a set of rules and objectives that were set to make sure EHRs are implemented in a way that enables the five pillars of health. Supported by the Health Information Technology for Economic and Clinical Health (HITECH) Act, meaningful use involves using health information technology to:

  • Improve the quality of health care
  • Reduce health disparities
  • Engage patients (and their families)
  • Coordinate health care
  • Ensure privacy and security of patient information

The goals of meaningful use are to improve population health, increase transparency, empower patients, and provide more robust research data.

The transition to meaningful use was planned as a staged process, with three main phases unfolding over a period of five 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 reimbursement. By 2019, all eligible professionals, eligible hospitals, dual-eligible hospitals, and critical access hospitals were required to use the 2015 edition certified EHR technology.

Privacy and Security

There 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., wearable tracking devices), so most are not regulated by this legislation. This makes ongoing revisions and oversight necessary and in the interest of privacy and security.

Patient Access

Many health providers now offer patient portals, which are secure websites from which you can access your electronic health record (or parts of it). These online accounts also typically facilitate different aspects of personal health care management, including communicating with practitioners, scheduling appointments, requesting medication refills, updating/correcting record details, and more.

These play a significant role in improving the mechanics of health care and make patients feel more like equal partners in the process.

While they may allow patients to enter some of their data, patient portals are primarily a window into the electronic health records maintained and controlled by the providers. They are "tethered" to the electronic medical record and subject to the strict HIPAA privacy rules that apply to medical organizations.

You may access multiple portals if your primary care provider and specialty providers use different systems, or you may only need to use one if you are a member of a health maintenance organization (HMO), as as all of your providers use the same system.

Clinical Decision Support

Clinical 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 EHRs.

CDSS models rely on data from live sample groups. Patient information is combined with evidence-based guidelines to generate optimal recommendations and treatment suggestions. EHRs can connect multiple sources of information and deliver personally-relevant information based on predictive algorithms.

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 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.

PHRs vs. EHRs

Personal health records (PHRs) or personal medical records (PMRs) are distinct from EHRs. These applications are designed to be set up by, maintained, and controlled by the patient, rather than the medical provider. You may be able to allow your health providers access to send and receive information to and from your PHR, but you also may enter the data yourself.

This data might be from the EHR of different providers, manually entered notes, or readings from home medical equipment such as your home blood pressure monitor, blood glucose monitor, etc.

A PHR may be stand-alone software or an app you use on your mobile device, or it may be a website provided by your employer or health plan. A PHR might not be a comprehensive health care record because it may rely on you to update information from several providers (each of which may have their own patient portal).

Unless the PHR is offered by a healthcare provider or health plan and tethered to your legal medical record, it is not covered by the strict privacy rules of HIPAA like EHRs are.

A Word From Verywell

You have a vested interest in making sure your medical records are being handled correctly, as well as stored and shared properly. Similar to your credit report, it is wise to monitor your medical information for accuracy and reasons of prudence.

HIPAA specifies that accessing and obtaining your health information for your own purposes is a right, not a privilege. This includes accessing an electronic copy of your health information contained in any electronic health record.

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Article Sources

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  6. Centers for Medicare & Medicaid Services. Promoting Interoperability. Updated July 2, 2019.

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  9. U.S. Department of Health and Human Services Office of Civil Rights. Personal health records and the HIPAA privacy rule.

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