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
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.”
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.