Introduction to Electronic Health Records (EHRs)

Objectives:

  • Learn the basics of EHR functionality
  • Learn the benefits, both clinical and financial, of using an EHR
  • Become familiar with basic EHR terms

Learn the EHR Basics

Overview of the EHR

The Electronic Health Record (EHR)– then called the Electronic Medical Record (EMR) or Computerized Patient Record (CPR)– received it first real validation in an Institute of Medicine's (IOM) report in 1991 entitled "The Computer-Based Patient Record: An Essential Technology for Health Care.(www.nap.edu)" IOM drove home the idea that the EHR is needed to transform the health system to improve quality and enhance safety.

The specialty of family medicine has also stated that the EHR is a core technology for the future of family medicine in the Future of Family Medicine Project. This project outlines a "New Model" of care for family medicine with the EHR as "the central nervous system" of that model. The EHR becomes a tool through which the family medicine office can transform practices to meet its needs and the needs of its patients. Enhanced workflows and access to information make the practice of medicine more efficient for physicians and their staff. Decision support and automated reminders help the practice deliver safer and higher quality care to patients and the community.

The EHR is about quality, safety, and efficiency. It is a great tool for physicians, but cannot ensure these virtues in isolation. Achieving the true benefits of EHR systems requires the transformation of practices, based on quality improvement methodologies, system and team based care, and evidence-based medicine.

Basic Terminology

The following is a list of basic terms you will need to know as you navigate the EHR market:

  • Certification - This relates to a national effort to "certify" various requirements for EHR software. The Certification Commitee for Health Information Technology (CCHIT) is tasked with determining what basic "must have" features EHR systems contain in order to be "certified."
  • Electronic Health Record (EHR) - This term refers to computer software that physicians use to track all aspects of patient care. Typically this broader term also encompasses the practice management functions of billing, scheduling, etc.
  • Electronic Medical Record (EMR) - This is an older term that is still widely used. It has typically come to mean the actual clinical functions of the software such as drug interaction checking, allergy checking, encounter documentation, and more.
  • Integrated EHR - This refers to an EHR that is integrated with practice management software. Typical choices include purchasing a fully integrated product which performs all the functions of practice management software, or a stand-alone EHR which is compatible with an existing practice management system.
  • Structured and unstructured data entry - There are several ways of entering data into your EHR as you practice. These include dictating straight into the software (voice recognition), templates, and writing (handwriting recognition).
  • Templates - Pre-structured portions of the software for common and/or basic visits. These templates fill in a standard set of data which you may then customize for each individual visit. Templates can be used with dictation, writing, or choosing among a menu of options formulated for each specific template.

Potential Benefits of an EHR

Benefits of an EHR can be categorized as follows:

Potential Productivity and Financial Improvement

  • Fewer chart pulls
  • Improved efficiency of handling telephone messages and medication refills
  • Improved billing
  • Reduced transcription costs
  • Increased formulary compliance and clearer prescriptions leading to fewer pharmacy call backs
  • Improved coding of visits

Additional potential benefits may include: population management and proactive patient reminders; improved reimbursement from payers due to EHR usage; and participation in pay-for-performance programs.

Quality of Care Improvement

  • Easier preventive care leading to increased preventive care services
  • Point-of-care decision support
  • Rapid and remote access to patient information
  • Easier chronic disease management
  • Integration of evidence-based clinical guidelines

Job Satisfaction Improvement

  • Fewer repetitive, tedious tasks
  • Less "chart chasing"
  • Improved intra-office communication
  • Access to patient information while on-call or at the hospital
  • Easier compliance with regulations
  • Demonstrable high-quality care

Customer Satisfaction Improvement

  • Quick access to their records
  • Reduced turn-around time for telephone messages and medication refills
  • A more efficient office leads to improved care access for patients
  • Improved continuity of care (fewer visits without the chart)
  • Improved delivery of patient education materials