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Electronic Health Records

This guide is intended to provide you with useful information for research and practice related to electronic health records, including journal articles, books, health data standards and other internet resources.

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Yimin Geng
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Definition and Functionality

An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. Check here for more information about EHR systems. 

'Key Capabilities of an Electronic Health Record System', identified in an Institute of Medicine (IOM) report , is a set of 8 core care delivery functions that electronic health records (EHR) systems should be capable of performing in order to promote greater safety, quality and efficiency in health care delivery.

The eight core functions are

  • health information and data - patients' diagnoses, allergies, lab test results, and medications etc.
  • result management - the ability for all providers participating in the care of a patient in different settings to  quickly access new and past test results.
  • order management - the ability to enter and store orders for prescriptions, tests, and other services in order to enhance legibility, reduce duplication, and improve the speed with which orders are executed.
  • decision support - using reminders, prompts, and alerts, computerised decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices.
  • electronic communication and connectivity - efficient, secure, and readily accessible communication among providers and patients to improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.
  • patient support - tools that give patients access to their health records, provide interactive patient education, and help them carry out home-monitoring and self-testing can improve control of chronic conditions
  • administrative processes and reporting - computerized administrative tools, such as scheduling systems, to improve hospitals' and clinics' efficiency and provide more timely services to patients.
  • reporting and population health - electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to reporting requirements, including those that support patient safety and disease surveillance.

The US Department of Health and Human Services (HHS) and HL7 standards define the electronic health record as "An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization." (Office of the National Coordinator for Health Information Technology, DHHS, 2008. "Defining Key Health Information Technology Terms".) This report understated that “Interoperability is the common thread running through health IT terms. Interoperability is the essential factor in building the infrastructure to create, transmit, store and manage health-related information.”

Interoperability

A widely used definition for interoperability is: Interoperability is ability of two or more systems or components to exchange information and to use the information that has been exchanged. (IEEE standard computer dictionary: a compilation of IEEE standard computer glossaries. New York: Institute of Electrical and Electronics Engineers; 1990.)

The HL7 EHR Interoperability Work Group has developed a framework, which covers three different points of view (Gibbons et al. 2007):

• Technical interoperability
• Semantic interoperability
• Process interoperability

These concepts are interdependent, and all three are needed to deliver significant business benefits. Semantic interoperability, the ability of the recipient to use the exchanged information, is the core of what we usually mean by healthcare interoperability. Standards are extremely important for sharing data in a networked environment. Standard-based semantic interoperability in EHRs is limited and the challenges of interoperability remain.

From: Benson, T. (2010). Principles of health interoperability HL7 and SNOMED. New York: Springer.