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| 08/23/2007 11:17 PM, Tim Armstrong. |
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| Electronic Health Record |
An electronic health record (EHR) refers to an individual patient's health record in digital format. Electronic health record systems co-ordinate the storage and retrieval of individual records with the aid of computers. EHRs are usually accessed on a computer, often over a network. It may be made up of electronic medical records (EMRs) from many locations and/or sources. A variety of types of healthcare-related information may be stored and accessed in this way.
EHR systems can reduce medical errors. In one ambulatory healthcare study, however, there was no difference in 14 measures, improvement in 2 outcome measures, and worse outcome on 1 measure.
EHR systems are believed to increase physician efficiency and reduce costs. They can also promote standardization of care.
Overlap in Terminology
Multiple terms have been used to define electronic patient care records, with overlapping definitions. Both electronic health record (EHR) and electronic medical record (EMR) have gained widespread use, with some health informatics users assigning the term EHR to a global concept and EMR to a discrete localised record. For most users, however, the terms EHR and EMR are used interchangeably. An EHR system is also often abbreviated as EHR or EMR.
Health Information Technology is an even broader term that describes any computer-based electronic aid to healthcare delivery.
Types of data stored in an electronic medical record
An electronic medical record might include:
* Patient demographics.
* Medical history, examination and progress reports of health and illnesses.
* Medicine and allergy lists, and immunization status.
* Laboratory test results.
* Radiology images (X-rays, CTs, MRIs, etc.)
* Photographs, from endoscopy or laparoscopy or clinical photographs.
* Medication information, including side-effects and interactions.
* Evidence-based recommendations for specific medical conditions
* A record of appointments and other reminders.
* Billing records.
* Advanced directives, living wills, and health powers of attorney
Advantages of electronic medical records over paper records
A medical record includes any of an individual's health documents of the types listed above. Medical records may be on "physical" media such as film (x-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces.
Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage.
When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant.
Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors. Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input.
Electronic records keeping and order entry were found to reduce errors associated with handwritten documents and were recommended for widespread adoption. |
| 08/24/2007 06:19 PM, Tim Armstrong. |
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