Electronic Health Records

Abstract

Forces are aligning to shift American health care into the Information Age: an age which financial institutions, airlines, supermarkets and most manufacturing industries have already entered. The shift, which these institutions have already experienced, will facilitate the establishment and widespread use of standardized databases in health care. The databases are known by the terms electronic medical records (EMRs), electronic health record (EHRs) or personal health records (PHRs). These forces underlie today's shift towards full use of a universally accepted electronic medical record, electronic health record and for a personal health record: An unprecedented revolution in computer and communication technologies The widespread availability of affordable electronic tools Burgeoning interest among patients in having access to their own medical information Rapid progress in understanding the human genome and proteosome The rising cost of health care The increasing administrative burden upon physicians A perception that medical errors are increasing Demands for widely comparable measures of quality care The need for post-marketing surveys of new drugs Our increasingly mobile society Greater emphasis upon evidence-based medicine Reimbursement incentives that pay for using EHRs and for providing quality care Reduced malpractice premiums for physicians that fully employ these technologies. What is an Electronic Health Record? An EMR contains the results of clinical and administrative encounters between a provider (physician, nurse, telephone triage nurse, and others) and a patient that occur during episodes of patient care. Consequently, the EMR reflects the practice style, job function, knowledge and skill of the providers who create it. It necessarily includes data structures and data elements that reflect those providers' systems. In an attempt to bring some structure to this emerging field, in 1991 the Institute of Medicine defined the basic functions of an EMR, then known as the computer-based patient record (CPR). The Institute of Medicine's definition remains the gold standard (see Table 1 on page 58). Table 1. EHR functions To supplement the provider-generated information in the EMR, the personal health record (PHR) is a medical record maintained by the patient. The PHR includes electronic copies of information patients have received from their providers. Finally, the concept of the EHR was formulated to integrate an individual's multiple, physician-generated, electronic medical records and the patient-generated personal health record. Intended to be comprehensive, the EHR should facilitate optimal management of the health of an individual or, when used in aggregate, of a population. EHRs should allow sharing of information about patients between any authorized providers. A patient should be able to enter any health care setting, provide authorization, and then consult with a provider who has ready access to his complete health record. EHRs should be securely linked over the Internet and should be integrated seamlessly with medical information for the education of both providers and patients. Table 2 lists common functions of an EHR divided by practice, clinical, system, and chemotherapy/drug management components. Table 2 lists some common medical and oncology-specific data elements (data fields) for an electronic health record. Table 2. Data elements for personal, provider, and oncology health records