Wikipedia source excerpts
ther information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.
For several decades, EHRs have been touted as key to increasing quality of care. EHR combines all patients' demographics into a large pool, which assists providers in the creation of "new treatments or innovation in healthcare delivery" to improve quality outcomes in healthcare. Combining multiple types of clinical data within electronic health records has enabled clinicians to identify and stratify patients with chronic conditions. EHR systems may also support improvements in quality of care through the use of data and analytics to help prevent hospitalizations among high-risk patients.
EHR systems are designed to store data accurately and to capture a patient's state across time. It eliminates the need to track down a patient's previous paper medical records and assists in ensuring data is up-to-date, accurate, and legible. It also allows open communication between the patient and the provider while providing "privacy and security." EHR is cost-efficient, decreases the risk of lost paperwork, and can reduce risk of data replication as there is only one modifiable file, which means the file is more likely up to date. Due to the digital information being searchable and in a single file, EMRs (electronic medical records) are more effective when extracting medical data to examine possible trends and long-term changes in a patient.
Terminology
The terms electronic health record (EHR), electronic patient record (EPR), and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist. The EHR is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR.
EMRs are essentially digital versions of the paper documents used in a clinician's office, typically functioning as an internal system within a practice. An EMR includes the medical and treatment history of patients treated by that specific practice.
In contrast, a personal health record (PHR) is an electronic application for recording individual medical data that the individual patient controls and may make available to health providers.
Comparison with paper-based records
While there is ongoing debate regarding the advantages of electronic health records compared with paper records, the research literature presents a more nuanced view of their benefits and limitations.
Increasing discontent and burnout among healthcare professionals is well documented as of 2023, with several studies finding that a leading cause of job frustration and increasing stress for most doctors and nurses is the increasing burden of increasingly complex record-keeping, paperwork, and administrative workloads.. Proponents of EHR note that these systems can substantially reduce such burdens, for example cutting time spent on insurance eligibility tasks by more than 80%.
But along with increased convenience, transparency, portability, and accessibility, there is also an increased risk that sensitive information may be accessed by unauthorized persons or unscrupulous users (versus paper medical records). This is acknowledged by the increased security requirements for electronic medical records included in the Health Insurance Portability and Accountability Act (HIPAA) and by large-scale breaches in confidential records reported by EMR users.
Meanwhile, handwritten paper medical records may be poorly legible, which can contribute to medical errors. Pre-printed forms, standardization of abbreviations, and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication. Medication is an intervention that can turn a person's status from stable to unstable very quickly. With paper documentation it is very easy to not properly document the administration of medication, the time given, or errors such as giving the "wrong drug, dose, form, or not checking for allergies," and could affect the patient negatively. It has been reported that these errors have been reduced by "55-83%" because records are now online and require specific steps to avoid these errors.
Electronic records may help with the standardization of forms, terminology, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies. However, standardization may create challenges for local practice. Overall, those with EMRs that have automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.
EMRs can be continuously updated (within certain legal limitations: see below). If the ability to exchange records between different EMR systems were perfected ("interoperability"), it would facilitate the coordination of health care delivery in non-affiliated health care facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management, and public health communicable disease surveillance.
Comparison with paper-based records
While there is ongoing debate regarding the advantages of electronic health records compared with paper records, the research literature presents a more nuanced view of their benefits and limitations.
Increasing discontent and burnout among healthcare professionals is well documented as of 2023, with several studies finding that a leading cause of job frustration and increasing stress for most doctors and nurses is the increasing burden of increasingly complex record-keeping, paperwork, and administrative workloads.. Proponents of EHR note that these systems can substantially reduce such burdens, for example cutting time spent on insurance eligibility tasks by more than 80%.
But along with increased convenience, transparency, portability, and accessibility, there is also an increased risk that sensitive information may be accessed by unauthorized persons or unscrupulous users (versus paper medical records). This is acknowledged by the increased security requirements for electronic medical records included in the Health Insurance Portability and Accountability Act (HIPAA) and by large-scale breaches in confidential records reported by EMR users.
Meanwhile, handwritten paper medical records may be poorly legible, which can contribute to medical errors. Pre-printed forms, standardization of abbreviations, and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication. Medication is an intervention that can turn a person's status from stable to unstable very quickly. With paper documentation it is very easy to not properly document the administration of medication, the time given, or errors such as giving the "wrong drug, dose, form, or not checking for allergies," and could affect the patient negatively. It has been reported that these errors have been reduced by "55-83%" because records are now online and require specific steps to avoid these errors.
Electronic records may help with the standardization of forms, terminology, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies. However, standardization may create challenges for local practice. Overall, those with EMRs that have automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.
EMRs can be continuously updated (within certain legal limitations: see below). If the ability to exchange records between different EMR systems were perfected ("interoperability"), it would facilitate the coordination of health care delivery in non-affiliated health care facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management, and public health communicable disease surveillance.