What Is an Electronic Health Record? All You Need to Know

9 min to read
Electronic health record
9 min to read

Whether you are a newcomer in healthcare, or you already successfully manage your clinic, but wish for modernization, it is worth considering implementing electronic health records. As we move into an ever more digital world, not implementing EMR or EHR in the near future may result in your practice being considered outdated or underperforming.

Nowadays, such records are familiar to most clinicians and have replaced almost all paper-based alternatives. Moreover, paper medical records are not only inconvenient but also may be slowing down your medical practice.

According to the Medical Economics Physician Report in 2018, at least 79% of clinicians, complained that inconvenient paperwork wasted precious time, effort and, therefore, money. Cost effectiveness is just one reason why physicians should consider involving electronic healthcare systems in their practices.

So, what is EHR? How does it work? How do you implement it? How much does it cost? Read on to learn the answers to all these questions, and more.

Example of the electronic health record

What is an Electronic Health Record?

EHR is a systematised electronic collection of patient health records, which are stored online so you they can be accessed anytime, anywhere. They were approved by the Institute of Medicine in 1991, and Soon became part of a healthcare revolution.

EHRs continue to gain popularity and have become widely-used - by 2017, nearly 9 in 10 physicians (90%) in the USA had replaced paper-based records with electronic health record software. EHR not only stores medical data, but also allows it to be shared. EHRs make health information accessible to authorised providers across health organisations, helping to better inform clinical decisions and coordinate patient care.

Statistics about electronic health record adoption

People often mistakenly think e-health record systems have the same usage and features as e-medical record systems. They are frequently used interchangeably, and are considered to be synonyms - it is essential to understand the differences in each system in order to compare EMRs and EHRs.

Electronic Medical Record systems, as well as EHRs, are used to document medical information on many patients over long periods of time. These systems organise and present data in ways that assist clinicians with:

⦁ interpreting health conditions

⦁ placing orders

⦁ providing ongoing care

⦁ scheduling

⦁ billing

The main distinction between the two is that EMRs aren't created to be shared with other practices, hospitals, pharmacies, etc.

However, it is important to note that both of these systems allow facilities and clinicians to provide better patient care than those using time-consuming paperwork.

EHR vs Paper Records

Nevertheless, paper records are becoming vestiges from the past due to their inconvenience and other significant disadvantages, which include:

Main Features of EHR Systems

EHR is widely used in clinics in most countries due to its relevant features, which make patient care robust and high-quality. An EHR platform sets up a patient portal, which allows secure data sharing and access to necessary information from other healthcare institutions. Its most useful features are outlined below.

Electronic Health Record systems:

⦁ provide patients and physicians with a secure, effective and timely mode of communication, as well as education and equity; security,

⦁ contain information about a patient's medical history, diagnoses, medications, treatment plans, immunisation dates, allergies, radiology images, and diagnostic, laboratory and test results;

⦁ allow access to a variety of sophisticated tools, including e-prescribing, speech recognition and dictation, advanced reporting, and more;

⦁ offer the ability to share a patient's medical data smoothly between the practitioners, clinicians, labs, hospitals and pharmacies that are authorised to access it;

⦁ save billing time and create a more accurate billing system.

Top 5 EHRs

When EHR systems are integrated with practice management solutions, these systems become the lifeblood of the medicare, which is why more and more EHR vendors appear in the world market every year.

Here are the top US-based EHR software vendors in 2019, according to market share:

Epic is an ambulatory EHR software rated #1 by KLAS Enterprises. It serves medical practices, hospitals, academic facilities, academic centres, health providers, groups and children's organisations. It is available on cloud, SaaS, web and mobile platforms to provides appointment scheduling, compliance tracking, voice recognition, and a self-service portal. The ease of use is rated about 3.9/5.

Cerner is the second-largest health software vendor. It produces clinical applications for small and medium-size organizations such as AMC, home care, clinician’s offices and private ambulatory care offices. It is available on Windows and macOS, and provides a clinical database, order completion, and clinical document management. The ease of use is rated about 3.5/5.

MEDITECH, an EHR software rated #3, targets small or medium-sized hospitals (up to 200 beds), but is currently only available on Windows. It allows users to document and chart a patient's data, set appointments and ask questions online. It handles revenue cycle management, as well as business analytics. The ease of use is rated about 3/5.

CPSI is a vendor of EHR solutions for rural and community hospitals, as well as post-acute care facilities. It is available on cloud, SaaS, web, macOS and Windows platforms and includes three point-of-care medication management modules: e-prescribing, medication reconciliation, and medication administration verification. The ease of use is rated about 2.5/5.

Allscripts is an ARRA-certified EHR designed to meet the needs of small and medium-sized physician’s practices. It facilitates e-prescribing, the personalisation of EHR by allowing organisations to choose which features they require, the automation of processes such as billing and patient medicine intake, and access to the clinical database. The ease of use is rated about 3.1/5.

Electronic health record market share

Main EHR Standards

EHRs cannot be implemented if they don't meet specific security standards and criteria.

EHR standards allow for reduced medical mistakes and costs, increased revenue, improved efficiency, and higher levels of physician services.

Such regulations are necessary if you are about to implement an EHR solution for your medical practice. If you are unaware of their need for compliance, the fundamental standards to follow when using EHRs are outlined below.

HIPAA requires providers and business associates to ensure the privacy and security of protected personal health information, in line with Privacy Policy rules.

The HITECH Act provides regulations designed to expand data breach notifications and to ensure the protection of electronically stored health information.

DICOM is an international standard for representing and forwarding healthcare image-based information.

HL7 is a standard of messaging between hospital and physician record systems.

ISO provides international technical specifications for EHRs and describes their architecture.

The Benefits of Electronic Health Records

EHR has not only improved paper records by turning them into online data, but it has also provided patients and clinicians with a greater variety of features. Its implementation has many more advantages than rifling through dusty archives. They could significantly improve health outcomes and help maintain better patient care, communication, and services.

Patient care benefits:

⦁ Every function is at hand: clinical alerts, reminders, appointment scheduling, messaging and clinical information.

⦁ Quick access to data, which reduces delays in treatment: EHR allows access to information anytime, anywhere.

⦁ When used for the management of chronic diseases, EHR allows for constant monitoring of symptoms, drug scheduling, and patient education.

Financial benefits:

⦁ Reduced storage and paper consumption costs - there is no longer any need to spend money on document storage and paper, which is also eco-friendly.

⦁ Billing accuracy - EHRs provide flexible and convenient online billing and payment options.

⦁ Better capturing of charges, resulting in a reduction in charge lag days and vendor/insurance denials associated with late filing.

Staff benefits:

⦁ Improved intra-office communication - EHRs provide integrated messaging systems, which can often be installed on mobile devices.

⦁ Simplification of data search tasks - clinicians can find necessary notes by entering a few keywords.

⦁ Increases work efficiency - EHRs allow scheduling, automated coding, and claims management, which saves significant time and effort.

Challenges in EHR Usage

Despite the substantial benefits, EHRs also come with some drawbacks which may be encountered during implementation or usage.

Medical data breach: EHR systems store information on servers that can be hacked. If they are not very well-secured, your patients may lose trust in your practice, leading to the loss of potential income and judicial proceeding against the organisation.

Solution: Limit access to the system for unauthorised users and provide staff members with a secure password and a personal ID to minimise security risks.

Data overload: Transfer of the paper-based healthcare records to the EHR software, can mean some medical notes are duplicated, mixed up, or lost. Patient data secured by Privacy Policy has a risk of loss, which can result in legal sanctions.

Solution: Arrange data transfers carefully, determine the number of documents be transferred in a particular time to avoid mixing them up or losing information.

Not user-friendly: The staff may be unfamiliar with, or confused by, the new EHR software, particularly if it contains lots of redundant functions and complicated user interface.

Solution: Even though specialised training requires additional time and expense, it can help clinicians to get acquainted with the new system and ensure they are ready to use it.

EHR Trends in 2019

The modern healthcare industry is constantly evolving, and it is crucial to monitor the latest trends in order s to provide comprehensive medical care which meets patient requirements.

Cloud-based EHRs (e.g. Amazing Charts, athenahealth, Practice Fusion)

Unlike standalone EHR systems, cloud EHRs don’t require complicated installation and have low maintenance costs.

Institutions such as OrthoAtlanta, DiToppa Medical Center and New England Quality Care Alliance have chosen cloud-based solutions and are now completely satisfied with them.

Electronic health record mobile app

EHR mobile apps (e.g. drchrono, Meditab, Medlium)

Imagine being unable to get quick access to a patient record when you need it because there is no computer nearby.

Usually, clinicians spend a lot of time in front of the computer, but are unable to make e-notes on the go. EHR mobile apps give physicians and patients an opportunity to manage data, provide medical care and communicate using mobile devices, no matter where they are.

Direct Urgent Cares and The Foot and Ankle are successful users of the drchrono solution. They have reinforced their positions as reputable medical institutions by establishing portable clinic systems with a full set of EHR features.

Electronic health record mobile app

Patient portals (e.g. RelayHealth, CPSI, Allscripts)

Without an opportunity to get quick access to information about test results, drug prescriptions and personal records, patients are unable to manage their own health and care or communicate with their physicians.

Portal adoption allows patients to get free access to their health information, fill out paperwork at home, conveniently arrange their appointments with their doctor and view consolidated lab results from different medical specialists.

Institutions such as Arbor Family Medicine, Kaleida Health and Specialty Eye Institute have experienced increased convenience by adopting patient portals provided by CPSI or Allscripts solutions that meet their patient's needs and demands.

Electronic health record by RelayHealth

Summary

To sum up, a significant number of medical practices would be unrecognisable without their implemented EHR systems.

These technologies enhance the overall working of medical practices, creating better experiences for physicians and their patients. However, the specific requirements and budget of your medical practice would play a central role in adopting these technologies.