Electronic Health Records (EHR)
Electronic health record (EHR)
•Basic Definitions with image and document links.
•Electronic Health Records (EHR)
•Personal Health Records (PHR)
•Continuity of Care Record (CCR)
Electronic patient chart of a health information system
•Adding Older Records
•Social and Organizational Issues
•Customization and Cost
Electronic Health Records (EHR)
•An electronic health record (EHR) is a distributed personal health record in digital
•The EHR provides secure, real-time, patient-centric information to aid clinical
decision-making by providing access to a patient's health information at the point of
•An EHR is typically accessed on a computer or over a network.
• It may be made up of health information from many locations and/or sources,
including electronic medical records (EMRs).
• An EHR almost always includes information relating to the current and historical
health, medical conditions and medical tests of its subject.
• In addition, EHRs may contain data about medical referrals, medical treatments,
medications and their application, demographic information and other non-clinical
•The ideal EHR system, as of 2006, has not been implemented by any software or
Electronic Health Records (EHR)
• An electronic medical record (EMR) is a patient medical record that contains
both documents in an electronic form and functions including:
• Patient demographics.
• Medical history, examination and progress reports of health and illnesses.
• Medicine and allergy lists, and immunization status.
• Scheduling, retrieval and archiving of laboratory and other tests.
• Graphic image display of X-rays, MRIs and other medical imaging studies.
• Medication ordering, including patient safety functions to minimize
interactions or side-effects.
• Evidence-based recommendations for specific medical conditions, termed
clinical practice guidelines.
• Appointment scheduling.
• Claims and payment processing.
• Patient reminders of follow up appointments, test completion, preventive
Electronic Health Records (EHR)
• The electronic health record (EHR) is all patient
medical information from multiple sources, including all
components of the EMR, accessible from any location by
any provider caring for the patient.
• In this ideal, the information is continuously updated and
current. Terms commonly used in describing the EHR
include interactive, interoperability, secure, real-time and
• The EHR allows collection of data for uses other than for
direct patient care, such as quality improvement,
outcome reporting, resource management, and public
health communicable disease surveillance.
•A medical record is both a general term for an individual's health documents and
reports, or more specifically, and often a paper chart or folder containing this
•Because of the need for access at different care locations, a patient may have
multiple medical record folders at each location at which care or testing was
•Each record may contain partial information, and the process of unifying and
updating paper records is daunting.
• Handwritten reports or notes, manual order entry, non-standard abbreviations
and poor legibility lead to medical errors, according to the 1999 Institute of
Medicine (IOM) report. (Institute of Medicine (1999). To Err Is Human: Building a
Safer Health System (1999). The National Academies Press. Retrieved on 2006-
• The follow-up IOM report advised rapid adoption of electronic patient records,
electronic medication ordering, with computer- and internet-based information
systems to support clinical decisions.
Medical Records (IOM report)
Examples of Mistakes:
•The knowledgeable health reporter for the Boston Globe, Betsy Lehman, died from an
overdose during chemotherapy. Willie King had the wrong leg amputated. Ben Kolb was
eight years old when he died during ''minor" surgery due to a drug mix-up.
•These horrific cases that make the headlines are just the tip of the iceberg.
•Two large studies, one conducted in Colorado and Utah and the other in New York,
found that adverse events occurred in 2.9 and 3.7 percent of hospitalizations,
respectively. In Colorado and Utah hospitals, 6.6 percent of adverse events led to
death, as compared with 13.6 percent in New York hospitals. In both of these studies,
over half of these adverse events resulted from medical errors and could have been
•When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results
of the study in Colorado and Utah imply that at least 44,000 Americans die each year as
a result of medical errors.
•. More people die in a given year as a result of medical errors than from motor vehicle
accidents (43,458), breast cancer (42,297), or AIDS (16,516).
Personal Health Records (PHR)
•A personal health record is medical information in possession of an individual
patient or patient's non-professional caregiver.
• The format may be either paper documents, electronic media, or a combination. The
sources of the information include patient-generated lists, copies of reports from
physicians, hospitals and labs, legal documents such as living wills and health care
proxy forms, and insurance statements.
• Organizations such as the American Health Information Management Association
(AHIMA) encourage individuals to keep their own complete PHR, including any
information that a doctor may not have, such as exercise routines, dietary habits,
herbal or nonprescription medications, or results of home testing, such as home
blood pressure or sugar readings.
•Consumers can purchase PHRs from companies on the internet.
• According to AHIMA, 42 percent of US adults surveyed said they keep some
form of a personal health record. PHR is also available free of cost from several
Personal Health Records (PHR) (cont)
Sample list of information gathered for patient care
•History and Physical—descriptions of any major illness and surgeries you have had, any significant family history
of disease, your health habits, current medications, as well as what your provider found when examining you.
Progress Notes—notes made by your healthcare provider that reflect your response to treatment, their
observations, and plans for continued treatment
Consultation—opinion about your condition made by a physician other than your primary care physician
Physician's Orders—directions to other members of the healthcare team regarding your medications, tests, diets,
Imaging and X-ray Reports—description of the findings of x-rays, mammograms, ultrasounds, and scans.
Lab Reports—description of the results of tests conducted on body fluids. Common examples include throat
culture, urinalysis, cholesterol level, and complete blood count
Operative Report--documentation that describes surgery performed Pathology Report—description of tissue
removed during an operation and the diagnosis based on examination of that tissue
Discharge Summary—summary of a hospital stay, including the reason for admission, significant findings from
tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for
medications, activity, diet, and follow-up care
Continuity of Care Record (CCR)
•The Continuity of Care Record (CCR is a core data set of the most relevant and timely facts
about a patient's healthcare.
•It is to be prepared by a practitioner at the conclusion of a healthcare encounter in order to
enable the next practitioner to readily access such information.
• It includes a summary of the patient's health status (e.g., problems, medications,
allergies) and basic information about insurance, advance directives, care documentation, and
care plan recommendations. It also includes identifying information and the purpose of the
•The CCR may be prepared, displayed, and transmitted on paper or electronically, provided
the information required by this standard specification is included.
•However, for maximum utility, the CCR should be prepared in a structured electronic
format that is interchangeable among electronic health record (EHR) systems
• To ensure interchangeability of electronic CCRs, this standard specifies that XML coding is
required when the CCR is created in a structured electronic format. XML coding provides
flexibility that will allow users to prepare, transmit, and view the CCR in multiple ways, e.g., in
a browser, as an element in an HL7 message or CDA compliant document , in a secure
email, as a PDF file, as an HTML file, or as a word processing document. It will further permit
users to display the fields of the CCR in multiple formats. . Equally important, it will allow the
interchange of the CCR data between otherwise incompatible EHR systems.
Although there are few standards for modern day electronic records systems as a whole, there
are many standards relating to specific aspects of EHRs and EMRs.
•ASTM Continuity of Care Record - a patient health summary standard based upon XML, the
CCR can be created, read and interpreted by various EHR or Electronic Medical Record
(EMR) systems, allowing easy interoperability between otherwise disparate enities.
•ANSI X12 (EDI) - A set of transaction protocols used for transmitting virtually any aspect of
patient data. Has become popular in the United States for transmitting billing information,
because several of the transactions became required by the Health Insurance Portability
and Accountability Act (HIPAA) for transmitting data to Medicare.
•CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
•CEN - EHRcom (EN 13606), the European standard for the communication of information
from EHR systems.
•CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical
•DICOM - a heavily used standard for representing and communicating radiology images
•HL7 - HL7 messages are used for interchange between hospital and physician record
systems and between EMR systems and practice management systems; HL7 Clinical
• Health Level Seven, Inc. (HL7), is an all-volunteer, not-for-profit
organization involved in development of international healthcare standards.
• Headquartered in Ann Arbor, Michigan, U.S., Health Level Seven is
a Standards Developing Organization (SDO) that is accredited by
the American National Standards Institute (ANSI).
• Founded in 1987 to produce a standard for hospital information
systems, HL7 is currently the selected standard for the
interfacing of clinical data in most institutions .
• HL7 and its members provide a comprehensive framework (and
related standards) for the exchange, integration, sharing and
retrieval of electronic health information.
• The standards, which support clinical practice and the management,
delivery, and evaluation of health services, are the most commonly
used in the world
HL7 Standards (cont)
• The HL7 organization has grown from a 14 members in 1987 to over 2200
members worldwide, including 500 corporate members today and
international affiliates in thirty three countries.
• Collectively, they develop standards designed to increase the
effectiveness, efficiency and quality of healthcare delivery
• In fact, HL7’s primary mission is to create flexible, low-cost standards,
guidelines, and methodologies to enable the exchange and
interoperability of electronic health records.
• Such guidelines or data standards are an agreed-upon set of rules that
allow information to be shared and processed in a uniform and consistent
• Without data standards, healthcare organizations could not readily share
• Theoretically, this ability to exchange information should help to minimize
the tendency for medical care to be so geographically isolated and highly
HL7 Standards (cont)
• Today HL7 standards development initiatives include the following:
• standardization of knowledge representation (Arden syntax)
• specification of components for context management (known as CCOW)
• support for healthcare data interchange using object request brokers
– In distributed computing, an object request broker (ORB) is a piece of middleware software that allows
programmers to make program calls from one computer to another, via a network.
• extend interoperability for the development of Health Information Exchange
• standardization of XML document structures
– The Extensible Markup Language (XML) is a general-purpose markup language. Its primary
purpose is to facilitate the sharing of data across different information systems. XML is a generic
framework for storing any amount of text or any data whose structure can be represented as a tree
structure. This means that the text must be enclosed between a root opening tag and a
corresponding closing tag. The following is a well-formed XML document:
– <book>Gallia omnia divisa est in partes tres .... </book>
• specification of robust vocabulary definitions for use in clinical messages and documents (cf.
SNOMED CT, LOINC)
– SNOMED (Systematized Nomenclature of Medicine), is a systematically organised computer
processable collection of medical terminology
• functional specifications for an electronic health record
• work in the area of security, privacy, confidentiality, and accountability.
•Architecture (CDA) documents are used to communicate documents such as
physician notes and other material.
•The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard
intended to specify the encoding, structure and semantics clinical documents for
IHE - Integrating the Healthcare Enterprise; while not a standard itself, IHE is a
consortial effort to integrate existing standards into a comprehensive best-practice
•ISO - ISO TC 215 has defined the EHR, and also produced a technical
specification ISO 18308 describing the requirements for EHR Architectures.
•openEHR - next generation public specifications and implementations for EHR
systems and communication, based on a complete separation of software and
United States Standards Organizations
•Not-for-profit organizations such as:
-the American Society for Testing and Materials (ASTM)
-Health Level 7 (HL7) and Healthcare Information and Management -
-Systems Society (HIMSS) are involved in the standardization process for
EHR in the United States.
-The Certification Commission for Healthcare Information Technology
(CCHIT) is a private not-for-profit organization founded to develop
and evaluate the certification for EHRs and interoperable health
•In Europe, CEN's TC/251 is responsible for EHR standards
-while at a global level, ISO TC215 produces standards for EHR
requirements as well as accepting certain standards from other standards
-CEN/TC 251 works on compatibility and interoperability between
independent systems and to enable modularity in Electronic Health
-The openEHR Foundation develops and publishes EHR specifications
and open source EHR implementations, which are currently being used in
Australia and parts of Europe.
Canada Health Infoway (a private not-for-profit organization started with
federal government seed money) is mandated to accelerate the
development and adoption of electronic health information systems.
•As of 2006, adoption of EHRs and other health information technology (HIT),
such as computer physician order entry (CPOE), has been minimal in the United
•Less than 10% of American hospitals have implemented HIT
• while a mere 16% of primary care physicians use EHRs.
•The vast majority of healthcare transactions in the United States still take
place on paper, a system that has remain unchanged since the 1950s.
•The healthcare industry spends only 2% of gross revenues on HIT, which is
meager compared to other information intensive industries such as finance,
which spend upwards of 10%.
• The following issues are behind the slow rate of adoption:
•In healthcare, interoperability is the ability of different information
technology systems and software applications to communicate, to
exchange data accurately, effectively, and consistently, and to use
the information that has been exchanged.[
The Center for Information Technology Leadership described four different
categories (“levels”) of data structuring at which health care data exchange can take
Adding of Older Records
•To attain the wide accessibility, efficiency, patient safety and cost savings
promised by EHR, older paper medical records ideally should be incorporated into
the patient's record.
•The digital scanning process involved in conversion of these physical records to
EMR is an expensive, time-consuming process, which must be done to exacting
standards to ensure exact capture of the content.
•Because many of these records involve extensive handwritten content, some
of which may have been generated by different healthcare professionals over
the life span of the patient, some of the content is illegible following
•The material may exist in any number of formats, sizes, media types and
qualities, which further complicates accurate conversion.
•In addition, the destruction of original healthcare records must be done in a
way that ensures that they are completely and confidentially destroyed.
•Results of scanned records are not always usable; medical surveys found that
22-25% of physicians much less satisfied with the use of scanned document
images than that of regular electronic data.
•A major concern is adequate confidentiality of the individual records being managed
•According to the Los Angeles Times, roughly 150 people (from doctors and
nurses to technicians and billing clerks) have access to at least part of a patient's
records during a hospitalization, and 600,000 payers, providers and other entities
that handle providers' billing data have some access also.
• Multiple access points over an open network like the internet increases possible
patient data interception. In the United States, this class of information is referred
to as Personal Healthcare Information (PHI) and access is regulated by the
Department of Health and Human Services (DHHS) under the Health Insurance
Portability and Accountability Act (HIPAA) and local laws.
• However, according to the Wall Street Journal, the DHHS takes no action on
complaints under HIPAA, and medical records are disclosed under court orders
in legal actions such as claims arising from automobile accidents.
•HIPAA has special restrictions on psychotherapy records, but
psychotherapy records can also be disclosed without the client's knowledge
or permission, according to the Journal.
Social and Organizational Barriers
•According to the Agency for Healthcare Research and Quality’s National Resource
Center for Health Information Technology, EHR implementations follow the 80/20 rule;
• that is, 80% of the work of implementation must be spent on issues of change
•while only 20% is spent on technical issues related to the technology itself.
•Such organizational and social issues include
•dealing with physicians' resistance to change
•creating a collaborative environment that fosters communication between
physicians and information technology project managers.
• Exemplifying this need are several highly publicized HIT implementation
fiascos, including one at Cedars Sinai Medical Center in Los Angeles, in
which physicians revolted and forced the administration to scrap a $34
Legal Status of EHR’s
•Medical records, such as physician orders, exam and test reports are legal
documents, which must be kept in unaltered form and authenticated by the creator.
•The individually defined Legal Health Record (LHR) for each healthcare provider
forms the basis for response to subpoenas and other legal processes that require
evidentiary use of the patient's 'medical record'.
•Digital signatures Most national and international standards accept electronic
•According to the American Bar Association. "A signature authenticates a writing
by identifying the signer with the signed document. When the signer makes a
mark in a distinctive manner, the writing becomes attributable to the signer.“
• With proper security software, electronic authentication is more difficult to falsify
than the handwritten doctor's signature.
•However, as the recent rise in identity theft demonstrates, no security
method can totally prevent fraud, so auditing information security will
continue to be prudent when using EMR.
Customization and Cost
•Pricing for Electronic Health Record (EHR) systems is highly dependent on each
practice's unique needs.
• Because every medical practice has distinct requirements, systems usually
need to be custom tailored.
•This is due to the majority of EHR systems being based on templates that are
initially general in scope.
• In many cases, these templates can then be customized in co-operation with the
vendor/developer to better fit a medical specialty, environment or other specified
•In a 2006 survey by the Medical Records Institute, lack of adequate funding was
cited by the 729 health care providers responding as the most significant barrier
to adopting electronic records.
• At the American Health Information Management Association conference in
October 2006, panelists estimated that purchasing and installing EHR will cost
over $32,000 per physician, and maintenance about $1,200 per month.
•Hidden costs may also include office workflow disruption during training or data
re-entry required by a new system, with fewer patient visits and less income.
US medical groups' adoption of EHR (2005)