Introduction to the Electronic Health Record (EHR)
What is an EHR?
An electronic health record (EHR) is a digital version of a medical record. It contains all the health-related information on an individual that can be created, gathered, managed, and consulted by authorized healthcare clinicians and staff.
The idea of the EHR has been present since the initial usage of computers in our healthcare industry during the late 1960s and early 1970s. However, the EHR has experienced momentous enhancement since that time.
EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.
They have the potential to provide substantial benefits to physicians, clinic practices, and health care organizations while facilitating workflow and improving the quality of patient care and patient safety.
How did the EHR come about?
Original, key energies to automate clinical data arose in the late 1960s and early 1970s. More than a few avant-garde universities and corporations recognized the worth of evolving information technology (IT) for healthcare.
In 1964, initial documented efforts to create a clinical information system (CIS) for a hospital were accomplished at Stanford University, in addition to the El Camino Hospital in the heart of Silicon Valley, by means of scientists at Lockhead Martin. In 1971, Lockheed sold it’s HIS group to Technicon Data Systems. In 1973, El Camino went live with the first computerized physician order entry (CPOE) system (Rootenberg June 2004).
An additional groundbreaking provider-vendor collaboration took place at Hospital of Intermountains Health Care, with the Health Evaluation Through Logical Processing (HELP) system, on which 3M has based products.
HELP was the first hospital information system to collect patient data needed for clinical decision-making and at the same time to incorporate a medical knowledge base and an inference engine to assist the clinician in making decisions.” (Gardner et al., 1999).
Other pioneers that have contributed significantly to research in the design of EHR include Akron Children’s Hospital and IBM; Massachusetts General Hospital in Boston; Kaiser Permanente in Oakland, California; and Regenstrief Institute in Indianapolis (Shortliffe and Perreault 2001).
How were the initial EHRs utilized?
Applicability of the first EHR projects remained in the settings in which they were formed – frequently in academic facilities.
These systems habitually could not be commercialized or made readily available in other locations because they were so thoroughly connected to methods at one establishment.
While commercial systems are much more the model currently, some of these early systems, as well as newer experiments, continue to exist.
Besides untried designs, initial applications were found to be deficient in the source systems – laboratory, radiology, pharmacy, and other ancillary services – to furnish an EHR with the data required to afford users with much value.
So, the computerization that arose in the 1980s fixated on the comparatively simpler but critical source systems and those that yielded more direct payback.
Primarily, these were administrative and financial systems, such as registration-admission/discharge/transfer (R-ADT), master person index (MPI), and patient accounting.
Afterwards, clinical department systems for laboratory, radiology, pharmacy, dietary, materials management, and others were established and applied. Interest in automating the health record itself faded during implementation of other systems.
How did these EHRs begin to evolve?
In the mid-1980s, unsatisfied by the insufficiencies of the paper medical record and the sluggish advancement toward automating clinical data for direct use by physicians, nurses, and other professional healthcare clinicians, the Institute of Medicine (IOM) initiated a study on improving the patient record considering new technology.
In 1991, the IOM published a report of its study, called “The Computer-based Patient Record: An Essential Technology for Health Care.” The IOM created the expression computer-based patient record (CPR), now referred to as the EHR.
At the time, the CPR signified a colossal jump from the notion of documentation that principally supported the provider to documentation that focused on the patient receiving healthcare.
IOM’s innovative work laid the theoretical basis for an idea of a system that would:
Provide a longitudinal (lifelong) record of events that may have influenced a person’s health (IOM 1991, 137) and reside[s] in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids (IOM 1991, 11).
The IOM decided to follow up its first patient record report with additional research in 1997. This revised edition observed that “Despite [a] milieu of rapid change, the vision outlined in [the original] report by the Committee on Improving the Patient Record remains remarkably on target, and the case for CPR is stronger today than it was six years ago.” It also noted “Plenty of room remains, however, to combine the depth of systems developed by institutions with easily modified, modular architecture, readily available technology, and the use of national standards
The report further stated “organizations seeking CPR face significant challenges in integrating various systems to achieve the full functionality they need. Moreover, CPR diffusion goes far beyond technology within an organization and relies at least as much on a change in culture that requires motivated, educated leadership within the institutions.” It concluded that a “coordinated national program for CPR advancement in the United Sates” was needed (IOM 1997, vi-ix).
The EHR certification criteria and associated standards, as well as meaningful use (MU) incentive objectives and measures, were proposed to enable substantial and measurable advances in population health by way of a transformed healthcare delivery system.
Health Information Technology (HIT) Policy Committee recommendations on MU requirements were structured around the National Quality Forum (NQF) Health Outcomes Policy Priorities (HIT Policy Committee 2009, 2011):
* Improve quality, safety, efficiency, and reduce health disparities
* Provide access to comprehensive patient health data for patient’s healthcare team
* Use evidence-based order sets and computerized provider order
* Apply clinical decision support at the point of care
* Generate lists of patients who need care and use list to reach out to patients
* Report information for quality improvement and public reporting
* Engage patients and their families in their healthcare
* Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and manage their health
* Improve care coordination
* Exchange meaningful clinical information among professional healthcare team
* Improve population and public health
* Communicate with public health agencies
* Ensure adequate privacy and security protections for personal health information
* Ensure privacy and security protection for confidential information through operating policies and procedures and technologies and compliance with applicable law
* Provide transparency of data sharing to patient
One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization.
The EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.
EHR pro: tons of information in the computerized medical record.
EHR con: tons of information in the computerized medical record.
Legal Nurse Consultants are vital to your reviews of EHRs
If there is a single fault in the recent EHR applications, it is that they are nearly entirely focused on direct care delivery functionality since their underlying database structure has been optimized to perform online transaction processing. This brings about a limited ability to develop reports for quality study or other functions, or much less generate a hard copy of the legal health record.
Technical limitations have made clinical information systems difficult to use in some cases. Plaintiff and defense attorneys engaged in health-related litigation review many cases each year.
Going through the voluminous medical records is essential to understanding the particulars of the case and reveal its strengths and weaknesses. But, you need an insider who knows the nature of the clinical information and the flow of clinical data through the healthcare system.
Structured data is vital to the automated clinical decision support process, but the “patient story” is also vital. Can you look at a chart, on any given day and time, and see the patient’s story?
Nurses work within the EHRs every day. We understand the drop-down boxes and check mark boxes. We can look through that haystack of records to find the needle that makes or breaks your case.
Legal nurse consultants provide dedicated medical record review services that are customized to meet the individual needs of each attorney.
Our purpose is to provide timely services that significantly lessen your workload.
We can help you work more efficiently, concentrating on more cases and improving your bottom line.
If you find this newsletter helpful, please share it with colleagues, or direct them to our website.
Amatayakul, M.K. (2013) Electronic Health Reocrds A Practical Guide for Professional and Organizations. Chicago, IL: AHIMA
Gardner RM, Pryor TA, Warner HR. The HELP hospital information system: update 1998. Int J Med Inf. 1999 Jun;54(3):169-82.
Health IT Policy Committee. 2009 (July 16). Recommendations to National Coordinator for Defining Meaningful Use. http://www.healthit.hhs.gov.
Health IT Policy Committee. 2011 (January 18). Meaningful Use Workgroup Request for Comments Regarding Meaningful Use Stage 2. http://www.healthit.hhs.gov.
Institute of Medicine. 1991. The Computer-Based Patient Record: An Essential Technology for Health Care, edited by R.S. Dick and E.B. Steen. Washington, DC: National Academies Press.
Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, edited by R.S. Dick and E.B. Steen, and D.E. Detmer. Washington, DC: National Academies Press.
Rootenberg, J. D. (June 2004). Waiting for e-Medicine (p. 51). Biotechnology: Essays from the Heartland. Bay Area Science and Innovation Consortium and California Institute for Quantitative Biomedical Research.
Shortliffe, E.H., and L.E. Perreault, eds. 2001. Medical Informatics: Computer Applications in Health Care and Biomedicine, 2nd ed. New York: Springer-Verlag.