An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all the key administrative clinical data relevant to that persons care under a provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.
EHR technologies automate access to information and streamlines the clinician’s workflow.
EHR technologies support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
At present, healthcare organizations are taking on the innovative transformations required to implement EHR technologies. These EHRs must include hardware, software, individuals, procedure, and process components in order to make this implementation effective.
Types of data systems that EHR technologies contain include:
Source systems
for gathering data. They are information systems that populate the EHR. Administrative, clinical and financial data are encompassed in this system.
Source systems include:
ancillary department information systems
dietary/food service information systems
emergency department information systems
laboratory information systems (LIS)
pharmacy information systems (PIS)
physical therapy information systems
radiology information systems (RIS)
Source systems are sometimes differentiated by clinical specialties (like oncology or neurology), or type of services (like emergency department or cath lab). Source systems consist of smart peripherals, such as smart infusion pumps or robotics as well.
Clinical systems
for using data at the point of care. Their purpose is providing for specific clinical functionality. Core clinical systems are frequently thought of as the applications that comprise an EHR. These systems define whether a healthcare organization has an EHR. They include:
Clinical decision support (CDS)
provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care.
CDS encompasses a variety of tools for EHR technologies to enhance decision-making in the clinical workflow.
These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.
Medication management systems
like computerized physician order entry (CPOE) which refers to any system in which clinicians directly place orders electronically with the orders transmitted directly to the recipient, electronic medical administration record (eMAR) – technology that automatically documents the administration of medication into certified EHR technology using electronic tracking sensors, and bar code medication administration record (BC-MAR) – pairs implementation of eMAR with item-specific identification (bar-coding).
Point-of-Care (POC) systems
clinicians enter data as they care for patients utilizing POC charting systems. These POCs are used for documentation including
taking a patient’s history, detailing physical exams and assessments, and composing physician progress notes or nurses’ notes.
Results management systems
diagnostic study results can be trended with other data, like medication administration.
Support systems
combine data from applications internal to a healthcare organization. Supporting infrastructure include:
clinical data repositories (CDRs)
a database that captures and sorts data in one location,
clinical data warehouses (CDWs)
a database allowing advanced data analysis for every service within the organization,
rules engine
controls reminders, order sets and protocols, and supplies CDR with programming logic for CDSS,
knowledge source
supplies data from external sources to rules engine,
presentation layer software and human-computer interfaces
facilitate data capture at POC,
report writers
assemble data into reports,
storage systems
(like storage area networks [SANs]) – back up and archive data.
Connectivity systems
support combination of data across different organizations and with patients or caregivers. A growing use of the EHR across the continuum of care, for quality measurement and reporting and for population health, is necessitating hardware and software that allows transmission of data across local and wide area networks in a secure and privacy-protected manner. The result has been the creation of various forms of health information exchange (HIE) among disparate organizations:
Continuity of care records (CCRs) and continuity of care documents (CCDs)
are standard specifications developed by different groups of organizations to achieve similar goals: improved continuity of healthcare, a reduction in medical errors, and improved health information transportability between patients, providers, and health care institutions.
It is particularly important to note that the CCD or CCR is not the underlying personal health record itself; rather it is an interchange.
The CCD and CCR provide the ability for one record to extract information, and for the next record to insert the information extracted into its own system.
Personal health records (PHRs)
to which providers and individuals contribute data and which assist individuals in managing consent for disclosure of information.
Technology for connectivity
like portals offering remote access to medical records for physicians or patients.
HIEs may include the ability for health plans to contribute comprehensive problem lists and medication lists to provide or individuals’ PHRs and for providers to add data to public health departments.
Source systems, Core clinical systems and Supporting infrastructure systems can be standalone systems within a hospital. But in the ambulatory care environment, they tend to be connected.
Clinical information systems ensure maximum effectiveness when the data is cohesive across all the systems and with data from all sources. Technical elements of the EHR systems, consistent with policy, must be present for individuals to utilize for the numerous processes they carry out.
EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians. The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.