Electronic Health Record

The 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. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider's office and can be inclusive of a broader view of a patient's care.

History

EHRs are rooted in the larger movement towards improved information technology that began in the 1960s. The push for EHRs gained significant momentum in the early 2000s with the advent of the Internet and technological advances. In 2009, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) was signed into law, which promoted the adoption and meaningful use of health information technology.

Components

EHR systems are designed to store data accurately and to capture the state of a patient across time. It eliminates the need to track down a patient's previous paper medical records and assists in ensuring data is accurate and legible. Core components of an EHR include:

• Patient demographics
• Progress notes
• Problems
• Medications
• Vital signs
• Past medical history
• Immunizations
• Laboratory data
• Radiology reports

Benefits

The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface, including evidence-based decision support, quality management, and outcomes reporting. Key benefits include:

• Improved patient care
• Increased patient participation
• Improved care coordination
• Increased practice efficiencies and cost savings
• Enhanced privacy and security of patient data

Challenges

Despite the benefits, EHR implementation has faced challenges including financial issues, changes in workflow, temporary loss of productivity associated with EHR adoption, and privacy concerns. Additionally, interoperability between different EHR systems and providers remains a significant hurdle.

Future Directions

The future of EHR involves enhanced interoperability, improved usability, and the integration of artificial intelligence to aid in diagnostics and patient care planning. The goal is to create a seamless network where all health information is available to all stakeholders efficiently and securely.

See Also

• Health informatics
• Medical privacy
• Patient safety
• Health Information Exchange