What are electronic health records (EHRs)?

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What are electronic health records (EHRs)?

EHRs are the simplest, digital (computerized) versions of patients' paper charts and information. It has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. According to experts, electronic health records contain significantly fewer errors than paper records. EHRs are real-time, patient-centered records.

They make information available instantly, "wherever and whenever it is needed". EHRs can:

  • Carry the information about a patient's medical history, diagnoses, medications, immunization, allergies, radiology, lab data and test results
  • Offer access to evidence-based tools that can be used in making decisions about patient's care
  • Improve the communication between physicians, hence, allowing each party to full access to patient’s medical history rather than a snapshot-type overview from a current visit.
  • Allow more in-depth evaluation and enable doctors to reach an accurate diagnosis quickly
  • Automate and streamline the workflow
  • Increase organization and accuracy of patient information
  • Can provide critical, life-saving information to emergency care providers

One of the key features of an EHR is that it can be created, managed, and consulted by authorized providers and staff across more than one health care organization.

A single EHR can bring together information from current and past doctors, emergency facilities, school and workplace clinics, pharmacies, laboratories, and medical imaging facilities.

Information in an electronic health records

An electronic health record contains patient health information, such as:

  • Administrative and billing data
  • Patient demographics
  • Progress notes
  • Vital signs
  • Medical histories
  • Diagnoses
  • Medications
  • Immunization dates
  • Allergies
  • Radiology images
  • Lab and test results

EHR systems are built to share information with other health care providers and organizations, including laboratories, medical imaging facilities, pharmacies, emergency facilities, schools and workplace clinics. So, they contain information from all clinicians involved in a patient’s care.

Adopting electronic health records

EHRs lead to tangible improvements in the health care providers' ability to make better decisions with more comprehensive information. EHR adoption can give health care providers:

  • Accurate and complete information about a patient's health. This helps in giving patient the best possible care, whether during a routine office visit or in a medical emergency, by providing the information needed to evaluate a patient's current condition in the context of the patient's health history and other treatments.
  • The ability to quickly provide care. In a crisis, EHRs provide instant access to information about a patient's medical history, allergies, and medications. This can enable providers to make decisions sooner, rather waiting for test results.
  • The ability to better coordinate the care to be provided, especially, if a patient has serious or chronic medical condition, such as diabetes.
  • A way to share information with patients and their family caregivers. Hence, patients and their families can participate in decisions about their health care.

The promise of fully realized EHRs is having a single record that includes all of a patient's health information: a record that is up to date, complete, and accurate. This puts providers in a better position to work with their patients to make good decisions.

EHRs can also flag potentially dangerous drug interactions, verify medications and dosages, and reduce the need for potentially risky tests and procedures.

Facts and figures: embracing EHR adoption

Based on a recent study by the National Center for Health Statistics, over two-thirds (71%) of EHR adopters would purchase their EHR system again and nearly one-half of physicians currently without an EHR system plan to purchase or use one already purchased within a year.

Percent distribution of electronic health record satisfaction among office-based physicians:

EHRs in health care quality and convenience

Electronic health records can improve the health care quality and can also make health care more convenient for both providers and patients.

A) Improved Quality and Convenience for Health Care Providers

  • Quick access to patient records from inpatient and remote locations for more efficient care
  • Enhanced decision support, clinical alerts, reminders, and medical information
  • Performance improving tools, real-time quality reporting
  • Legible documentation that facilitates accurate coding and billing
  • Interfaces with labs, registries, and other EHRs
  • Safer and more reliable prescribing

B) Improved Health Care Quality and Convenience for Patients

  • Reduces same form filling at every office visit
  • Reliable point-of-care information and reminders notifying health care providers of important health interventions
  • Convenience of e-prescriptions electronically sent to pharmacy
  • Patient portals with online interaction for providers
  • Electronic referrals allowing easier access to follow-up care with specialists

EHRs in medical practice efficiency and cost savings

Many health care providers believe that electronic health records help in improving the medical practice management by increasing the practice efficiency and cost savings.

A national survey of doctors who are ready for use offers important evidence:

  • 79% health care providers reported more efficiency in their practice functions with EHRs.
  • 82% reported of saved time by sending prescriptions electronically (e-prescribing)
  • 75% received lab results faster
  • 70% reported of enhancement in data confidentiality

Savings are primarily attributed to automating several time-consuming paper-driven and labor-intensive tasks

  • Reduced transcription costs
  • Reduced chart pull, storage, and re-filing costs
  • Improved and more accurate reimbursement coding with improved documentation for highly compensated codes
  • Reduced medical errors through better access to patient data and error prevention alerts
  • Improved patient health/quality of care through better disease management and patient education

EHRs for more efficient practices

EHRs helps in more efficient practices as it:

  • Improves medical practice management through integrated scheduling systems that link appointments directly to progress notes, automate coding, and managed claims
  • Saves time with easier centralized chart management and condition-specific queries.
  • Enhances communication with other clinicians, labs, and health plans through:

   -Easy access to patient information

   -Tracking electronic messages to staff, other clinicians, hospitals and labs.

   -Automated formulary checks by health plans

   -Order and receipt of lab tests and diagnostic images

   -Links to public health systems such as registries and communicable disease databases

Paperwork reduction by electronic health records

EHRs can reduce the amount of time spent in paperwork. It prevents the administrative tasks, including filling forms and processing billing requests, thus decreases overall cost. In addition, EHRs can deliver more information in additional directions. EHRs can be programmed for easy or even automatic delivery of information that needs to be shared with public health agencies or for quality measurement.

Electronic Prescribing (E-Prescribing)

Paper prescriptions can get lost or misread. With electronic prescribing (e-prescribing), doctors communicate directly with the pharmacy. An e-prescribing system can save lives (by reducing medication errors and checking for drug interactions), lower costs, and improve care. It is more convenient, cheaper for doctors and pharmacies, and safer for patients. In short, e-prescribing is an important, high-visibility component of progress in health information exchange.

EHRs reduces duplication of testing

Because EHRs contain all of a patient's health information in one place, it is less likely that providers will have to spend time ordering and reviewing the results of duplicate/unnecessary tests and medical procedures. Less utilization means lesser cost.

Advantages of electronic health records

EHRs and the ability to exchange health information electronically can help health care providers with higher quality and safer care for patients.

  • Provides accurate, up-to-date, and complete information about patients at the point of care
  • Enables quick access to patient records for more coordinated and efficient care
  • Securely shares electronic information with patients and other clinicians
  • Helps health care providers in more effectively diagnose patients and reduce medical errors
  • Improves patient and health care provider interaction and communication for overall health care convenience
  • Enables safer and more reliable prescription
  • Helps in promoting legible, complete documentation and accurate, streamlined coding and billing
  • Enhances privacy and security of patient data
  • Improves productivity and work-life balance of physicians
  • Improves the efficiency and helps health care providers in meeting their business goals
  • Reduces costs through decreased paperwork, improved safety, reduced duplication of testing and improved health

Other advantages

Transformed healthcare

Electronic Health Records (EHRs) are the first step to transformed health care. The benefits of electronic health records include:

  • Better health care by improving all aspects of patient care, including safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity.
  • Better health by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventative care.
  • Improved efficiencies and lower health care costs by promoting preventative medicine and improved coordination of health care services, as well as by reducing waste and redundant tests.
  • Better clinical decision making by integrating patient information from multiple sources.

How to implement EHRs

  1. Assessing Practice Readiness: The first step includes the assessment of physician's current practice, its goals, needs, and financial and technical readiness. With an accurate view of the level of preparedness, designing of an implementation plan with specific needs of practice can be done.
  2. Planning to Approach: Planning draws on the information gathered during the assessment phase, to outline the practice's EHR implementation plan.
  3. Select or Upgrade to a Certified EHR: There are a number of steps involved in choosing the right EHR system for physician's practice. Eligible health care professionals and eligible hospitals must use certified EHR technology to achieve meaningful use and qualify for incentive payments.
  4. Training & Implementing EHR System: EHR implementation involves the installation of the EHR system and associated activities including training, mock go-live, and pilot testing.
  5. Achieving Meaningful Use: The final phase of EHR implementation includes successfully attesting to demonstrating meaningful use of EHRs, and reassessing learned skills from training and everyday use of the system.
  6. Continue Quality Improvement: Emphasizes continuous evaluation of practice's goals and needs post-EHR-implementation to continue improving workflows that achieve the individual practice's goals while leveraging the functionality of electronic health records.

If your patients lack trust in Electronic Health Records (EHRs) and Health Information Exchanges (HIEs), feeling that the confidentiality and accuracy of their electronic health information is at risk, they may not want to disclose health information to you. Withholding their health information could have life-threatening consequences. To reap the promise of digital health information to achieve better health outcomes, smarter spending, and healthier people, providers and individuals alike must trust that an individual’s health information is private and secure.

Exploratory, Electronic health records (EHR), Health Information Exchanges (HIEs), Patient centred records, Informative article
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