- What is an electronic health record?
- EHR systems: how has EHR evolved over the years?
- What is the difference between EHR and EMR?
- What EHR solution will suit your organization?
- Essential EHR features
When you switch from paper to electronic records for your medical company, you need to weigh the pros and cons of this change and understand what the EHR system needs to consist of.
The transition process should be well-organized and match your requirements. You should also keep in mind the importance of the security of the medical data stored in your healthcare institution.
What is an electronic health record?
According to the Office of the National Coordinator for Health Information Technology (ONC), an electronic health record (EHR) is a digital version of a patient’s medical reports. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.
EHRs contain medical and treatment histories of patients, allow access to evidence-based tools that providers can use to make decisions about patient care, and they automate and streamline provider workflow. EHR is a medical software built to securely document, store, retrieve, share, and analyze information about individual patients.
EHR systems: how has EHR evolved over the years?
Electronic health record software has had a long path of development. One of the first successful attempts to streamline and improve the keeping of patient records was made in the 1960s. It was the problem-oriented medical record (POMR) developed by Dr. Lawrence Weed. The system provided a structure that helped doctors record their notes about patients, and view those notes in a manner that gave them a good understanding of that patient’s history. The POMR structure included five things:
- List of problems
- Initial planning
- Daily progress notes
- Discharge summary
In the 1970s the world’s first EHR systems appeared. In 1972 the Regenstrief Institute in Indianapolis announced the EHR program developed by Clement McDonald and the team of collaborators. This team wrote code in accordance with the core principles underlying the structure of modern databases. The first major organization to implement such a system was the Veterans Administration, which called the system VistA (the Veterans Health Information System and Technology Architecture). Its capabilities included:
- Ordering medications
- Nursing orders
- Lab tests
However, the adoption of EHR was costly and complicated, so for the next 20 odd years, EHRs were few and far between due to the absence of capabilities to transmit the information rapidly, securely, and affordably.
Everything changed in the 1990s when the Internet became a common tool. The perception of an EHR as a mirror of old-fashioned paper records shifted to the technology that assists clinicians today. The advances in computer technology made EHR software much more affordable, even for small practices. A bit later the development of the Internet resulted in deployable cloud-based EHRs, which allowed sharing information not only with other healthcare providers but also with patients, creating the trend of patient engagement.
The Health Insurance Portability and Accountability Act (HIPAA), adopted in 1996, was a response to the growing tide of electronic medical information. The provisions of HIPAA and its compliance, which became a structural foundation for the next wave of EHR evolution, were aimed at protecting patients and making vendors responsible for compliance.
This new wave of development, which started in the early 2000s, is related to standardization and adaptation of electronic health record systems. Physical, technical, and administrative safeguards were introduced for health record software including:
- Data encryption
- Access control
- Audit trails
- Automatic data backups
- Automatic logoffs
The trend for standardization resulted in the adoption of industry-wide standards and the establishment of agencies and organizations developing such standards as Health Level 7 International. Another trend that gained traction in the 2000s is the move toward integrated and centralized systems that provide access to all of a patient’s data through a single system.
Today EHRs are an integral part of almost every medical practice, In 2017 the adoption rate reached 96% for US hospitals.
What is the difference between EHR and EMR?
Very often the terms EHR (electronic health record) and EMR (an electronic medical record) are confused.
According to the EHR definition in the HITECH Act, the term ‘electronic health record’ is an electronic record of health-related information on an individual that is created, gathered, and managed by authorized healthcare clinicians and staff.
An EMR is the digital equivalent of a paper record at a doctor’s office containing general patient information including treatment and medical history collected by individual medical practice. Using a simple analogy, an EMR is a chapter in a patient’s medical history, while an EHR is a whole book with the full story, reference index, and illustrations.
The core differences between an EHR and an EMR:
- An EMR is mainly used for diagnosis and treatment at a single provider.
- EMRs are designed for use by individual practice and not for sharing between organizations.
- EHRs are designed to share a patient’s information with authorized providers and staff from more than one organization.
- EHRs allow a patient’s medical information to be exchanged between specialists, labs, imaging facilities, emergency rooms, and pharmacies, as well as across state lines.
What EHR solution will suit your organization?
The increasing demand for centralization and streamlining of electronic healthcare systems, technological advancements in the field of healthcare IT, and increasing awareness about the use and importance of EHRs mean that a suitable EHR/EMR system will give you advantages over your competitors, ensure a deep physician-patient interaction and enrich the patient’s experience.
The big question is what features your solution should have. The set of features and the solution structure depend on the requirements you have for the solution. Each medical practice is unique and has individual needs. For example, a dental practice will need practice management software different from the software needed for managing a large multi-specialty hospital.
There may be an EHR system broad enough to adequately serve any business, but a specialized platform that is tailored to your practice gives you more advantages in terms of cutting costs and improving adoption, resulting in better overall patient care. To select the right solution, you have to identify your organization’s specific needs to provide the best patient care.
Essential EHR features
An EHR/EMR solution allows one to streamline care delivery and help a provider attest to meaningful use.
Here is a list of the key capabilities of an electronic health record system:
- Real-time reporting: Meaningful use reporting is real-time access to clinical and financial data that enables the utilization of big data and analytics, thus providing actionable insights and evidence-based decision making.
- Patient scheduling: Easy patient scheduling allows the medical office staff to make appointments, register patients, and choose a reason for the visit. Automatic appointment reminders help reduce no-shows and ensure better data collection.
- Patient encounters: Smooth and fast patient encounters allow a doctor or facility to see more patients in a day. Easy access to patient records like medications taken, allergies, existing problems, immunizations, and other key data points speed up the patient charting process. Patient data entry must be fast and convenient for clinical staff, and there needs to be checked in place to eliminate possible errors when entering data.
- Patient workflow tracking allows real-time tracking of patient flow in the facility to eliminate bottlenecks.
- Task management allows for streamlining of management of ancillary tasks necessary for everyday healthcare delivery. An intelligent EHR system should feature reminders to sign notes, review lab results, approve medications, answer patient messages, etc.
- Communication and care coordination is an important feature necessary for the continuity of care and the improvement of the patient experience.
- Templates and order sets allow for building templates to treat patients with the same conditions and similar diagnoses, thus speeding up the clinical encounter.
- Result management allows one to analyze patient outcomes and provide insights on how to improve treatment.
- 24/7 access to patient records from any device or computer that can access the software. Security is of vital importance at this level.
- A simple user-friendly interface allows the entire clinical encounter to be visible on a single screen, with drag-and-drop capabilities and minimal screen openings.
Based on the specifics of the healthcare provider, the functionality of the EHR system can be customized to suit your direct needs and some additional EMR features can also be embedded such as:
- Clinical interoperability
- Patient portal
- Decision support
Of course, this list could be much longer depending on what your company needs to streamline the process of care provision. Whatever your decision is – whether that is to develop a solution from scratch or to buy a ready-made solution from a vendor – the determinative factor is the real value it can bring to your business.
Archer Software has over 20 years of experience in healthcare IT and our portfolio includes mobile applications, web services, online platforms, and software in the healthcare industry.
Get in touch with us at firstname.lastname@example.org to evaluate your project, and get a custom and fully secure solution that meets the needs of your business.