Electronic Health Records at a Glance

For several years, the healthcare industry has been talking about Electronic Health Records.  This article mainly deals with what exactly is Electronic Health Records or EHR and what are its key building components? Electronic health record also known as Electronic Medical Record is the  most vital element in health information infrastructure now-a-days. Health Information Management Systems Society’s (HIMSS) definition of EHRs. It reads:  “The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician’s workflow. 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.”

By definition, EHR is a longitudinal record, but it is important to note that EHR is not a longitudinal record of all care provided to the patient in all venues over time. Longitudinal records may be kept in a nationwide or regional health information system. But an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office.

The first known medical record was developed by Hippocrates, in the fifth century B.C. He prescribed two goals:

• A medical record should accurately reflect the course of disease.
• A medical record should indicate the probable cause of disease.

These goals are still appropriate, but electronic health records systems can also provide additional functionality, such as interactive alerts to clinicians, interactive flow sheets, and tailored order sets, all of which can not be done be done with paper-based systems.   The first EHRs began to appear in the 1960s. By 1965, Summerfield and Empey reported that at least 73 hospitals and clinical information projects and 28 projects for storage and retrieval of medical documents and other clinically-relevant information were underway.  Some of the early notable projects were:

• COSTAR (the Computer Stored Ambulatory Record), Barnett, et al., developed Harvard, placed in the public domain in 1975 and implemented in hundreds of sites worldwide.
• HELP (Health Evaluation through Logical Processing), Warner, et al., developed at Latter-Day Saints Hospital at the University of Utah (brought to market by the 3M Corporation). HELP is notable for its pioneering decision support features.
• TMR (The Medical Record), Stead and Hammond, Duke University Medical Center.
• THERESA, Walker, at Grady Memorial Hospital, Emory University, notable for its success in encouraging direct physician data entry.4
• CHCS (Composite Health Care System), the Department of Defense’s (DoD) clinical care patient record system used worldwide.
• DHCP (De-Centralized Hospital Computer Program), developed by the Veteran’s Administration and used nationwide.
• TDS, developed by Lockheed in the 1960s and 1970s.

These early projects had significant technical and programmatic issues, including non-standard vocabularies and system interfaces, which remain implementation challenges today.

EHRs are used in complex clinical environments. Features and interfaces that are very appropriate for one medical specialty, such as pediatrics, may be frustratingly unusable in another (such as the intensive care unit). The data presented, the format, the level of detail, and the order of presentation may be remarkably different, depending on the service venue and the role of the user.

An electronic record may be created for each service a patient receives from an ancillary department, such as radiology, laboratory, or pharmacy, or as a result of an administrative action (e.g., creating a claim). Some Academic Medical Centre’s clinical systems also allow electronic capture of physiological signals (e.g., electrocardiography), nursing notes, physician orders, etc. Often, these electronic records are not integrated, they are captured—and remain—in silo systems, which each have their own user log-ins and their own patient identification systems.

Components of EHR

Most commercial EHRs are designed to combine data from the large ancillary services, such as pharmacy, laboratory, and radiology, with various clinical care components (such as nursing plans, medication administration records [MAR], and physician orders). The EHR, therefore, may import data from the ancillary systems via a custom interface or may provide interfaces that allow clinicians to access the silo systems through a portal.  The components are :

Administrative System Components :  Registration, admissions, discharge, and transfer (RADT) data are key components of EHRs. These data include vital information for accurate patient identification and assessment, including, but not necessarily limited to, name, demographics, next of kin, employer information, chief complaint, patient disposition, etc. The registration portion of an EHR contains a unique patient identifier, usually consisting of a numeric or alphanumeric sequence that is unidentifiable outside the organization or institution in which it serves. RADT data allows an individual’s health information to be aggregated for use in clinical analysis and research.

Laboratory System Components: Laboratory systems generally are standalone systems that are interfaced to EHRs. Typically, there are laboratory information systems (LIS) that are used as hubs to integrate orders, results from laboratory instruments, schedules, billing, and other administrative information. Laboratory data is integrated entirely with the EHR only infrequently. Even when the LIS is made by the same vendor as the EHR, many machines and analyzers are used in the diagnostic laboratory process that are not easily integrated within the EHR.

Radiology System Components:  Radiology information systems (RIS) are used by radiology departments to tie together patient radiology data (e.g., orders, interpretations, patient identification information) and images. The typical RIS will include patient tracking, scheduling, results reporting, and image tracking functions. RIS systems are usually used in conjunction with picture archiving communications systems (PACS), which manage digital radiography studies.

Pharmacy System Components: Pharmacies are highly automated in AMCs and in other large hospitals as well. But, again, these are islands of automation, such as pharmacy robots for filling prescriptions or payer formularies, that typically are not integrated with EHRs.

Computerized Physician Order Entry :  Computerized physician order entry (CPOE) permits clinical providers to electronically order laboratory, pharmacy, and radiology services. CPOE systems offer a range of functionality, from pharmacy ordering capabilities alone to more sophisticated systems such as complete ancillary service ordering, alerting, customized order sets, and result reporting.

Clinical Documentation:  Electronic clinical documentation systems enhance the value of EHRs by providing electronic capture of clinical notes; patient assessments; and clinical reports, such as medication administration records (MAR).  Examples of clinical documentation that can be automated include Physician, nurse, and other clinician notes, Flow sheets (vital signs, input and output, problem lists, MARs), Peri-operative notes, Discharge summaries, Transcription document management, Medical records abstracts etc.

Advantages

EHR have several advantages over Paper Health Records.  Some of the advantages are :

• Increased  storage capabilities for longer periods of time.
• Accessible from remote sites to many people at the same time.
• Continuously updated and is available concurrently for use everywhere.
• Provide medical alerts and reminders.
• Have built-in intelligence capabilities, such as recognizing abnormal lab results, or potential life- threatening drug interactions.
• Reduce healthcare costs.

Disadvantages

Some of the disadvantages include such items as the startup costs, which can be excessive. Another disadvantage to an EHR is that there is a substantial learning curve and it is helpful if the users have some type of technical knowledge. Today, clinicians are the primary users of EHRs as opposed to the main users of the past, which where clerks. One of the more challenging issues confronting EHRs is the fact that physicians must be the users of the system, performing data entry (e.g., orders, progress notes) as well as information retrieval, if they are to realize the benefits of interactive on-line decision support.  Confidentiality and security issues are other concerns associated with both the paper health record and the EHR.