What are Electronic Health Records (EHR)? Best Practices

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Datavant
June 13, 2024

What are electronic health records?

Electronic Health Records (EHRs) are digital versions of a patient's medical history that healthcare providers maintain over time. They include key health information, such as medical history, diagnoses, medications, treatment plans, immunization dates, allergies, lab and test results, and radiology images.

EHRs can be created, managed, and consulted by authorized healthcare providers and staff across different healthcare organizations. They are designed to go beyond standard clinical data to provide a broader view of a patient’s care and make health information available to patients and their doctors instantly, thereby enhancing the overall quality of care.

What are the common features of electronic health records?

Electronic health records come with a variety of features that streamline healthcare delivery and improve patient care. Common features include:

Patient demographics 

EHRs include basic information such as age, gender, contact details, and insurance information. This data is essential for identifying patients and ensuring accurate billing. Having up-to-date demographic information also helps in analyzing patient populations and improving care delivery.

Medical history 

EHRs provide a comprehensive record of past illnesses, surgeries, family medical history, and lifestyle factors. This information helps healthcare providers understand the patient's overall health. It also aids in making informed decisions about treatment and preventive care.

Medication management 

EHRs track current and past prescriptions, dosage information, and refills. This feature helps prevent medication errors and adverse drug interactions. It also allows providers to monitor patient compliance and manage long-term treatments more effectively.

Order entry 

Electronic ordering of tests, medications, and procedures is a key feature of EHRs. This reduces errors related to handwriting and miscommunication. It also speeds up the processing of orders, improving efficiency and patient care.

Clinical notes 

EHRs store detailed notes from healthcare providers documenting patient encounters and care plans. These notes provide a clear record of the patient's progress and treatment. They are essential for continuity of care and for communicating with other providers.

Lab and imaging results 

Integration of laboratory test results and radiology images allows quick access and review. This feature helps providers make timely and accurate diagnoses. It also facilitates the sharing of results with other healthcare professionals involved in the patient's care.

Decision support 

EHRs include alerts and reminders for preventive measures, drug interactions, and critical lab values. These tools support providers in making evidence-based decisions. They also help in maintaining high standards of patient safety and care.

Patient portal 

A secure online portal allows patients to view their health information, communicate with providers, and schedule appointments. This feature empowers patients to take an active role in their healthcare. It also enhances the convenience and efficiency of healthcare services.

What's the difference between electronic health records and electronic medical records?

Definition and scope 

Electronic health records are comprehensive digital records of a patient's entire health history, accessible across different healthcare settings. EHRs include data from various providers and can be shared with authorized users to coordinate care. In contrast, electronic medical records (EMRs) are digital versions of paper charts in a single provider’s office and are typically not shared outside of that practice.

Interoperability 

EHRs are designed for interoperability, meaning they can exchange information seamlessly with other EHR systems. This allows for better coordination of care among different healthcare providers and facilities. EMRs, however, are generally limited to internal use within one healthcare practice and do not easily share data with other systems.

Comprehensive care vs. specific treatment 

EHRs support comprehensive care by providing a holistic view of a patient's health, including all treatments and interactions across multiple providers. This broad scope helps in managing chronic conditions and preventive care. EMRs focus on the medical treatment provided by a single healthcare provider, covering the clinical data specific to that provider's interactions with the patient.

Patient access 

Patients typically have access to their EHRs through patient portals, allowing them to view their health information, lab results, and medication lists. This access encourages patient engagement and self-management. EMRs usually do not provide direct access for patients, as they are intended for use within a specific provider's practice.

What are electronic health record standards?

Electronic health record standards ensure the compatibility and interoperability of EHR systems across different healthcare settings. These standards enable consistent and secure sharing of patient information among providers, enhancing the quality and continuity of care.

Health Level Seven (HL7)

HL7 is a set of international standards for the exchange, integration, sharing, and retrieval of electronic health information. These standards facilitate communication between various healthcare systems. HL7 covers a wide range of data types and ensures that different systems can work together seamlessly.

Fast Healthcare Interoperability Resources (FHIR)

FHIR is a standard describing data formats and elements for exchanging electronic health records. It is designed to enable easy and fast data exchange, even on mobile devices. FHIR allows developers to create applications that can access and use health data, promoting innovation in healthcare IT.

Clinical Document Architecture (CDA)

CDA is an HL7 standard that defines the structure of clinical documents. It ensures that documents like discharge summaries and progress notes are formatted consistently. This consistency makes it easier to share and understand clinical information across different systems and providers.

DICOM (Digital Imaging and Communications in Medicine)

DICOM is the standard for handling, storing, and transmitting medical imaging information. It ensures that images and related data can be exchanged and viewed on different medical imaging devices and systems. This standard is crucial for the integration of radiology and imaging into EHRs.

ICD-10 (International Classification of Diseases)

ICD-10 is a coding system used to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care. It provides a standardized way to represent health conditions, which is essential for billing, reporting, and research. Using ICD-10 codes in EHRs helps ensure accuracy and consistency in medical records.

What are the benefits of electronic health records?

Electronic health records offer numerous advantages that enhance both patient care and healthcare operations. These benefits include improved patient care, increased efficiency, better data accessibility, and more.

Improved patient care

EHRs provide healthcare providers with complete and accurate patient information. This leads to better decision-making and more coordinated care. Patients receive more timely and effective treatments, reducing the risk of medical errors.

Enhanced efficiency

EHRs streamline administrative tasks such as scheduling, billing, and documentation. This reduces the time and effort required for paperwork. Healthcare providers can focus more on patient care, improving productivity and satisfaction.

Better data accessibility

EHRs ensure that patient information is readily accessible to authorized users. This improves the continuity of care, as different providers can easily access and share patient records. Quick access to information also facilitates faster diagnosis and treatment.

Improved patient engagement

EHRs often include patient portals that allow individuals to access their health information. Patients can view test results, manage appointments, and communicate with their providers. This engagement helps patients take an active role in their own healthcare.

Enhanced security and privacy

EHRs are designed with robust security measures to protect patient information. Encryption, access controls, and audit trails help ensure data privacy and security. This reduces the risk of unauthorized access and data breaches.

Facilitated research and public health

EHRs provide valuable data for research and public health initiatives. Researchers can analyze large datasets to identify trends and improve treatments. Public health officials can use EHR data to monitor and respond to health threats more effectively.

What are the disadvantages of electronic health records?

While electronic health records offer many benefits, they also come with several challenges. These disadvantages include high implementation costs, complexity, and privacy concerns.

High implementation costs

Implementing EHR systems can be expensive, involving costs for software, hardware, and training. These initial costs can be a significant burden for smaller healthcare providers. Additionally, ongoing maintenance and upgrades add to the financial strain.

Complexity and learning curve

EHR systems can be complex and require significant time and effort to learn. Healthcare providers may need extensive training to use these systems effectively. This learning curve can temporarily reduce productivity and increase frustration among staff.

Privacy and security concerns

Despite robust security measures, EHRs are still vulnerable to cyberattacks and data breaches. Unauthorized access to patient information can lead to identity theft and privacy violations. Maintaining the security of EHR systems requires constant vigilance and investment.

Interoperability issues

Different EHR systems may not always communicate seamlessly with one another. This lack of interoperability can hinder the sharing of patient information across different healthcare settings. It can lead to incomplete records and fragmented care.

Technical issues and downtime

EHR systems are prone to technical glitches and downtime, which can disrupt healthcare operations. System failures can lead to delays in accessing patient information and providing care. Regular maintenance and reliable technical support are essential to minimize these issues.

How is electronic health record data stored?

Storing EHR data securely and efficiently is crucial for maintaining patient privacy and ensuring data accessibility. Different storage methods, including cloud-based and on-premises solutions, offer various benefits and challenges.

Cloud-based storage

Many EHR systems use cloud-based storage to house patient data. This method allows data to be accessed from anywhere with an internet connection, providing flexibility and convenience. Cloud storage also offers scalable solutions for growing data needs and includes robust security measures to protect patient information.

On-premises storage

Some healthcare providers prefer to store EHR data on local servers within their facilities. This on-premises storage can offer more control over data security and access. However, it requires significant investment in hardware, maintenance, and IT support.

Data encryption

Regardless of the storage method, EHR data is typically encrypted to protect it from unauthorized access. Encryption ensures that patient information remains secure during storage and transmission. This is a crucial measure for maintaining patient confidentiality and complying with regulations.

Regular backups

EHR systems often include regular data backup processes to prevent data loss. These backups can be stored in various locations, including off-site facilities, to ensure data recovery in case of hardware failure or other disasters. Regular backups help maintain the integrity and availability of patient records.

How to implement an electronic health record system

  1. Assess needs and goals
    Start by conducting a thorough analysis of your practice's workflow and patient care processes. Identify specific features you need, such as e-prescribing, lab integration, and patient portals. Set clear, measurable goals for what you want the EHR system to achieve, such as reducing paperwork or improving patient follow-up.
  1. Choose the right vendor
    Research and shortlist vendors that specialize in EHR systems for your type of practice. Schedule demonstrations and request case studies or references from similar healthcare providers. Assess each vendor's system for ease of use, integration capabilities, and support services to ensure a good fit for your needs.
  1. Plan and prepare
    Create a detailed project plan that outlines each step of the implementation process, including data migration, system configuration, and testing phases. Assign specific tasks and responsibilities to team members to ensure accountability. Ensure all necessary hardware is in place and compatible with the new EHR system.
  1. Train staff
    Develop a comprehensive training program tailored to different roles within your practice. Conduct hands-on training sessions focusing on daily tasks and workflows. Provide resources such as user manuals and quick reference guides, and establish a support system for ongoing questions and troubleshooting.
  1. Monitor and evaluate
    Set up a system for tracking key performance indicators (KPIs) such as patient wait times, documentation accuracy, and user satisfaction. Regularly review these metrics and gather feedback from staff and patients. Use this data to make necessary adjustments and improvements to the EHR system and processes.

What is the future of electronic health records?

The future of EHRs will involve greater integration with advanced technologies like AI and machine learning, enhancing data analysis and decision support. Efforts to improve interoperability will enable seamless data exchange between different healthcare providers, improving care coordination and reducing redundant tests. 

EHR systems will also focus on increased patient engagement through more robust patient portals, offering easier access to records and telemedicine capabilities. Enhanced data security measures will become crucial, with advanced encryption and multi-factor authentication protecting patient information. Additionally, EHRs will support personalized medicine by incorporating genomic data, allowing for treatments tailored to individual health profiles.

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Datavant's comprehensive, compliant, and secure data logistics solutions connect directly to your EHR to transform your healthcare data challenges into opportunities for growth and improved patient care. 

Contact Datavant today to transform how you handle clinical data and improve your patient experience.

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