Electronic health records explained

What is an EHR?

An electronic health record (EHR) is a digital repository of a patient’s medical information that documents their entire healthcare journey in real time. Everything from diagnoses, medical history, medications and immunizations, to X-rays, laboratory results and clinical notes, is updated automatically so that doctors and providers have the most recent information when they access a patient’s EHR.

So how do EHRs differ from electronic medical records (EMRs)? Simply put, EMRs are a digital version of a paper chart. They contain the medical and treatment history of the patient in one healthcare setting. Electronic health records go further. More than just notes from a single care provider, EHRs also include a range of functionalities (explored below) and can be shared among multiple providers such as laboratories and specialists. In other words, EHRs tell the whole story of a patient’s healthcare journey across providers, settings, treatments and conditions.

There are two types of EHR systems: inpatient and outpatient. Inpatient EHR systems are tailored for hospital settings, with a focus on interoperability across various departments. On the other hand, outpatient EHR systems cater to smaller doctors’ practices. Sometimes referred to as ambulatory EHRs, these systems include functionalities to streamline appointments, prescriptions and billing.

Key components of an EHR system

Each EHR system is made up of a network of components:

• Patient health information: At the heart of the EHR system lies a detailed digital record which includes medical histories, diagnostic records and medication details.
• Order entry systems: These allow for tests, medications and treatments to be ordered electronically, simplifying previously complicated workflows.
• Decision support systems: These systems provide evidence-based recommendations to healthcare professionals, delivering crucial information when needed.
• Security protocols: Strict access protocols ensure that patient information is stored securely and confidentially, accessible only to authorized individuals.
• Communication tools: These facilitate coordination among practitioners, laboratories and pharmacies, ensuring a unified approach to patient treatment.

Benefits of electronic health records

By giving healthcare providers easy access to comprehensive, up-to-date patient information, EHRs save a lot of time that could be spent filling in blanks in patient histories and investigating potential treatment risks. These digital records enable informed decision-making and personalized treatment plans while also boosting patient engagement by empowering individuals to access their own health information, communicate with their healthcare providers, and actively participate in their care.

There are significant electronic health record benefits on the admin front, too. Centralizing patient records in a digital format helps reduce the duplication of tasks, decreases the risk of human error, and makes it easier for providers to coordinate and deliver the best care. What’s more, over time a well-managed EHR system can lead to substantial cost savings by reducing paper-related expenses, minimizing administrative overheads, and preventing costly medical errors. By streamlining workflows and optimizing resources, EHRs contribute to a more sustainable and cost-effective healthcare delivery system.

Finally, EHRs can help hospitals and providers protect sensitive patient information from unauthorized access or breaches by applying robust encryption techniques, access controls, and audit trails.

Challenges to EHR deployment

Healthcare providers can face considerable challenges when implementing an EHR system in a clinic or hospital:

• Security breaches: While encryption and cybersecurity offer sophisticated safeguards to guarantee EHR privacy, digital records always carry a risk of violation. Providers must ensure that their transition from traditional record-keeping methods to EHRs can be underpinned by the appropriate and compliant security measures so that patients can continue on their healthcare journey with trust.
• Data storage limitations: Digital storage systems must be robust and scalable enough to accommodate vast amounts of patient data. Managing these requirements while ensuring data accessibility and integrity can pose a significant challenge during the transition process.
• Data inconsistencies: As with any technology, there remains a risk of error. Inaccuracies within patient records can arise from manual entry errors, outdated information or differences in coding standards. Addressing and rectifying these discrepancies is essential to maintaining the integrity and accuracy of patient data, and ensuring that healthcare providers have access to reliable and timely information for clinical decision-making.
• Interoperability: Healthcare providers may use different EHR software that may not communicate or share data seamlessly. This can lead to disruptions in patient care.
• Cost: Implementing EHRs requires substantial financial investment, including acquiring the EHR software, updating hardware, training, and ongoing maintenance. These fees affect smaller practices in particular.
• Training and support: Transitioning to an EHR system requires healthcare providers and staff to acquire new skills and adapt to unfamiliar technologies. Comprehensive training, as well as post-implementation support, is essential to ensure that personnel are proficient in using EHRs.

Transitioning to EHRs

Providers eager to transition to electronic health records can overcome these challenges in a number of ways. First of all, by planning ahead. After a thorough assessment of an organization’s unique needs, workflows and goals, providers can get to the task of selecting the right EHR system. Evaluating different vendors based on factors such as functionality, usability, interoperability and scalability is the first step on that journey.

Once a system has been selected, a detailed implementation plan outlining timelines, milestones and requirements will help ensure a smooth rollout. In parallel, it’s also important to consider factors such as budget, staff training, data migration and potential workflow changes. Planning ahead empowers providers to anticipate challenges and mitigate risks, setting the stage for a smooth transition process.

With those two hurdles overcome, it is important to communicate the upcoming changes to staff – the sooner, the better. It is especially important to collect feedback on usability and their experience along the transition process so that any pain points can be addressed early on. Investing in staff training will increase user confidence, minimize resistance to change, and ensure that the new system benefits both patients and practitioners.

Finally, it is paramount to communicate with the most important stakeholders of all: the patients. Open and transparent communication is essential throughout the transition to EHRs. Educating patients about the benefits of electronic health records, and addressing any concerns they may have about EHR privacy, security, or changes in the healthcare experience will build trust, reduce anxiety and promote engagement in the use of EHRs.

Using standards for a smooth transition

The successful implementation, testing and adoption of EHRs requires collaboration between healthcare professionals, patients and policymakers. International Standards can make this collaboration easier. One such standard, ISO 13606, was developed by a group of international experts to facilitate the secure and seamless exchange of health information between multiple EHR systems or between a system and a centralized data repository. These standards can promote interoperability, streamline data exchange, and uphold the confidentiality and integrity of patient health information.

• ISO 13606-1 Electronic health record communication – Part 1: Reference model

  ISO 13131 Telehealth services – Quality planning guidelines

The future of healthcare

While migrating from paper records to an EHR system has its challenges, the benefits are undeniable. Deploying an EHR system is a key step towards modernizing healthcare. These digital records provide a comprehensive view of a patient’s health journey, resulting in better patient outcomes, streamlined processes and long-term cost savings. As technology advances, EHRs will continue to evolve, shaping the future of healthcare and the way patients and providers interact.