An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs are a vital part of health IT and can:

• Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
• Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
• Automate and streamline provider workflow

One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.

Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online consumer health information that is relevant to the health conditions and treatments related to a specific patient.

What’s in a word? Or, even one letter of an acronym?

Some people use the terms “electronic medical record” and “electronic health record” (or “EMR” and “EHR”) interchangeably. But here at the Office of the National Coordinator for Health Information Technology (ONC), you’ll notice we use electronic health record or EHR almost exclusively. While it may seem a little picky at first, the difference between the two terms is actually quite significant. The EMR term came along first, and indeed, early EMRs were “medical.” They were for use by clinicians mostly for diagnosis and treatment.

In contrast, “health” relates to “The condition of being sound in body, mind, or spirit; especially…freedom from physical disease or pain…the general condition of the body.” The word “health” covers a lot more territory than the word “medical.” And EHRs go a lot further than EMRs.

What’s the Difference?

Electronic medical records (EMRs) are a digital version of the paper charts in the clinician’s office. An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to:

• Track data over time
• Easily identify which patients are due for preventive screenings or checkups
• Check how their patients are doing on certain parameters—such as blood pressure readings or vaccinations
• Monitor and improve overall quality of care within the practice

But the information in EMRs doesn’t travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record.

Electronic health records (EHRs) do all those things—and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.”

The information moves with the patient—to the specialist, the hospital, the nursing home, the next state or even across the country. In comparing the differences between record types, HIMSS Analytics stated that, “The EHR represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual.” EHRs are designed to be accessed by all people involved in the patients care—including the patients themselves. Indeed, that is an explicit expectation in the Stage 1 definition of “meaningful use” of EHRs.

And that makes all the difference. Because when information is shared in a secure way, it becomes more powerful. Health care is a team effort, and shared information supports that effort. After all, much of the value derived from the health care delivery system results from the effective communication of information from one party to another and, ultimately, the ability of multiple parties to engage in interactive communication of information.

Benefits of EHRs

With fully functional EHRs, all members of the team have ready access to the latest information allowing for more coordinated, patient-centered care. With EHRs:

• The information gathered by the primary care provider tells the emergency department clinician about the patient’s life threatening allergy, so that care can be adjusted appropriately, even if the patient is unconscious.
• A patient can log on to his own record and see the trend of the lab results over the last year, which can help motivate him to take his medications and keep up with the lifestyle changes that have improved the numbers.
• The lab results run last week are already in the record to tell the specialist what she needs to know without running duplicate tests.
• The clinician’s notes from the patient’s hospital stay can help inform the discharge instructions and follow-up care and enable the patient to move from one care setting to another more smoothly.

So, yes, the difference between “electronic medical records” and “electronic health records” is just one word. But in that word there is a world of difference.

Peter Garrett and Joshua Seidman PhD

Electronic Health Records: The Basics

An electronic health record (EHR) contains patient health information, such as:

• Administrative and billing data
• Patient demographics
• Progress notes
• Vital signs
• Medical histories
• Diagnoses
• Medications
• Immunization dates
• Allergies
• Radiology images
• Lab and test results

An EHR is more than just a computerized version of a paper chart in a provider’s office. It’s a digital record that can provide comprehensive health information about your patients. EHR systems are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.

Advantages of Electronic Health Records

EHRs and the ability to exchange health information electronically can help you provide higher quality and safer care for patients while creating tangible enhancements for your organization. EHRs help providers better manage care for patients and provide better health care by:

• Providing accurate, up-to-date, and complete information about patients at the point of care
• Enabling quick access to patient records for more coordinated, efficient care
• Securely sharing electronic information with patients and other clinicians
• Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care
• Improving patient and provider interaction and communication, as well as health care convenience
• Enabling safer, more reliable prescribing
• Helping promote legible, complete documentation and accurate, streamlined coding and billing
• Enhancing privacy and security of patient data
• Helping providers improve productivity and work-life balance
• Enabling providers to improve efficiency and meet their business goals
• Reducing costs through decreased paperwork, improved safety, reduced duplication of testing, and improved health.

Take the First Step:

1. Contact your local REC to find out if you are eligible for free or reduced-price support. Your local Regional Extension Center (REC) can help you realize the benefits of electronic health records. RECs are located in every region of the country to help health care providers select, implement, and become adept and meaningful users of EHRs.
2. Download Health IT Implementation Resources
3. Review the 6 Implementation Steps

Other Advantages

Transformed Health Care

Electronic Health Records (EHRs) are the first step to transformed health care. The benefits of electronic health records include:

• Better health care by improving all aspects of patient care, including safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity.
• Better health by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventative care.
• Improved efficiencies and lower health care costs by promoting preventative medicine and improved coordination of health care services, as well as by reducing waste and redundant tests.
• Better clinical decision making by integrating patient information from multiple sources.

Meaningful Use

One of the best ways to ensure you take full advantage of the benefits of electronic health records is to achieve meaningful use. By achieving meaningful use, you can reap benefits beyond financial incentives.

An electronic health record (EHR) is more than a digital version of a patient’s paper chart.

EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can:

Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results

Allow access to evidence-based tools that providers can use to make decisions about a patient’s care

Automate and streamline provider workflow

Impact of EHRs on Care

Our world has been radically transformed by digital technology – smart phones, tablets, and web-enabled devices have transformed our daily lives and the way we communicate. Medicine is an information-rich enterprise.

A greater and more seamless flow of information within a digital health care infrastructure, created by electronic health records (EHRs), encompasses and leverages digital progress and can transform the way care is delivered and compensated.

With EHRs, information is available whenever and wherever it is needed.

Improved Patient Care

Increase Patient Participation

Improved Care Coordination

Improved Diagnostics & Patient Outcomes

Practice Efficiencies and Cost Savings

Electronic health records (EHRs) can improve health care quality. EHRs can also make health care more convenient for providers and patients.

Snapshot of Improved Health Care Quality and Convenience for Providers

• Quick access to patient records from inpatient and remote locations for more coordinated, efficient care
• Enhanced decision support, clinical alerts, reminders, and medical information
• Performance-improving tools, real-time quality reporting
• Legible, complete documentation that facilitates accurate coding and billing
• Interfaces with labs, registries, and other EHRs
• Safer, more reliable prescribing

Snapshot of Improved Health Care Quality and Convenience for Patients

• Reduced need to fill out the same forms at each office visit
• Reliable point-of-care information and reminders notifying providers of important health interventions
• Convenience of e-prescriptions electronically sent to pharmacy
• Patient portals with online interaction for providers
• Electronic referrals allowing easier access to follow-up care with specialists

EHRs Improve Information Availability

With EHRs, patients' health information is available in one place, when and where it is needed. Providers have access to the information they need, at the time they need it to make a decision.

EHRs Can Be the Foundation for Quality Improvements

Reliable access to complete patient health information is essential for safe and effective care. EHRs place accurate and complete information about patients' health and medical history at providers' fingertips. With EHRs, providers can give the best possible care, at the point of care. This can lead to a better patient experience and, most importantly, better patient outcomes.

Practices also report that they utilize extracted reports on patient and disease registries to track patient care as well as facilitate quality improvement discussions during clinical meetings.

EHRs Support Provider Decision Making

EHRs can help providers make efficient, effective decisions about patient care, through:

• Improved aggregation, analysis, and communication of patient information
• Clinical alerts and reminders
• Support for diagnostic and therapeutic decisions
• Built-in safeguards against potential adverse events

Health Care Convenience Matters

Providers with busy practices—and patients with busy lives—appreciate convenience in their health care transactions. EHRs can help. For example, with e-prescribing, patients can have their prescriptions ordered and ready even before they leave the provider's office. Providers and their staff can often file insurance claims immediately from the provider's office. And providers may be able to access patient files or submit prescriptions remotely—from home or while on vacation.

Providers and patients who share access to electronic health information can collaborate in informed decision making. Patient participation is especially important in managing and treating chronic conditions such as asthma, diabetes, and obesity.

How EHRs Foster Patient Participation

Electronic health records (EHRs) can help providers:

• Ensure high-quality care. With EHRs, providers can give patients full and accurate information about all of their medical evaluations. Providers can also offer follow-up information after an office visit or a hospital stay, such as self-care instructions, reminders for other follow-up care, and links to web resources.
• Create an avenue for communication with their patients. With EHRs, providers can manage appointment schedules electronically and exchange e-mail with their patients. Quick and easy communication between patients and providers may help providers identify symptoms earlier. And it can position providers to be more proactive by reaching out to patients. Providers can also provide information to their patients through patient portals tied into their EHR system.

The Patient's Perspective

Information technology is at the heart of modern life. It touches different people in different ways. Some are comfortable with new technologies; others may be intimidated, at least at first. EHRs, PHRs, and other health IT developments tend to make many patients more active participants in their own health care. As providers adopt new technologies such as EHRs, it's important to keep the patient's perspective in mind.

The Need for Better, Improved Care Coordination

As medical practices and technologies have advanced, the delivery of sophisticated, high-quality medical care has come to require teams of health care providers—primary care physicians, specialists, nurses, technicians, and other clinicians.

Each member of the team tends to have specific, limited interactions with the patient and, depending on the team member's area of expertise, a somewhat different view of the patient. In effect, the health care team's view of the patient can become fragmented into disconnected facts and clusters of symptoms. Health care providers need less fragmented views of patients.

How EHRs Can Improve Care Coordination

Electronic health record (EHR) systems can decrease the fragmentation of care by improving care coordination. EHRs have the potential to integrate and organize patient health information and facilitate its instant distribution among all authorized providers involved in a patient's care. For example, EHR alerts can be used to notify providers when a patient has been in the hospital, allowing them to proactively follow up with the patient.

With EHRs, every provider can have the same accurate and up-to-date information about a patient. This is especially important with patients who are:

• Seeing multiple specialists
• Receiving treatment in emergency settings
• Making transitions between care settings

Better availability of patient information can reduce medical errors and unnecessary tests.

Better availability of information can also reduce the chance that one specialist will not know about an unrelated (but relevant) condition being managed by another specialist.

Better care coordination can lead to better quality of care and improved patient outcomes.

Leveraging an EHR across the continuum of care allows for:

Better integration among providers by improved information sharing

Viewable and up-to-date medication and allergy lists

Order entry at point of care or off-site

Standardization of data, order sets, and care plans helping to implement common treatment of patients using evidence-based medicine

Access to experts for rural health care providers by sharing best practices and allowing for specialized care through telemedicine

Population management trended data and treatment and outcome studies

More convenient, faster, and simpler disease management

When health care providers have access to complete and accurate information, patients receive better medical care. Electronic health records (EHRs) can improve the ability to diagnose diseases and reduce—even prevent—medical errors, improving patient outcomes.

A national survey of doctors who are ready for meaningful use offers important evidence:

• 94% of providers report that their EHR makes records readily available at point of care.
• 88% report that their EHR produces clinical benefits for the practice.
• 75% of providers report that their EHR allows them to deliver better patient care.

EHRs can aid in diagnosis

With EHRs, providers can have reliable access to a patient's complete health information. This comprehensive picture can help providers diagnose patients' problems sooner.

EHRs can reduce errors, improve patient safety, and support better patient outcomes

How? EHRs don't just contain or transmit information; they "compute" it. That means that EHRs manipulate the information in ways that make a difference for patients. For example:

• A qualified EHR not only keeps a record of a patient's medications or allergies, it also automatically checks for problems whenever a new medication is prescribed and alerts the clinician to potential conflicts.
• Information gathered by a primary care provider and recorded in an EHR tells a clinician in the emergency department about a patient's life-threatening allergy, and emergency staff can adjust care appropriately, even if the patient is unconscious.
• EHRs can expose potential safety problems when they occur, helping providers avoid more serious consequences for patients and leading to better patient outcomes.
• EHRs can help providers quickly and systematically identify and correct operational problems. In a paper-based setting, identifying such problems is much more difficult, and correcting them can take years.

Risk Management and Liability Prevention: Study Findings

EHRs May Improve Risk Management By:

• Providing clinical alerts and reminders
• Improving aggregation, analysis, and communication of patient information
• Making it easier to consider all aspects of a patient’s condition
• Supporting diagnostic and therapeutic decision making
• Gathering all relevant information (lab results, etc.) in one place
• Support for therapeutic decisions
• Enabling evidence-based decisions at point of care
• Preventing adverse events
• Providing built-in safeguards against prescribing treatments that would result in adverse events
• Enhancing research and monitoring for improvements in clinical quality

Certified EHRs May Help Providers Prevent Liability Actions By:

• Demonstrating adherence to the best evidence-based practices
• Producing complete, legible records readily available for the defense (reconstructing what actually happened during the point of care)
• Disclosing evidence that suggest informed consent

EHRs can improve public health outcomes

EHRs can also have beneficial effects on the health of groups of patients.

Providers who have electronic health information about the entire population of patients they serve can look more meaningfully at the needs of patients who:

• Suffer from a specific condition
• Are eligible for specific preventive measures
• Are currently taking specific medications

This EHR function helps providers identify and work with patients to manage specific risk factors or combinations of risk factors to improve patient outcomes.

For example, providers might wish to identify:

• How many patients with hypertension have their blood pressure under control
• How many patients with diabetes have their blood sugar measurements in the target range and have had appropriate screening tests

This EHR function also can detect patterns of potentially related adverse events and enable at-risk patients to be notified quickly.

Studies Show: Better Patient Outcomes With EHRs

Using EHR Prompts & Reminders to Improve Quality of Patient Care

High Patient Satisfaction

• 92% were happy their doctor used e-prescribing.
• 90% reported rarely or only occasionally going to the pharmacy and having prescription not ready.
• 76% reported it made obtaining medications easier.
• 63% reported fewer medication errors.

High Provider Satisfaction

• Reduced overall rate of after-hours clinic calls.

Using EHRs to Improve Quality of Care

Improved Quality of Care Screenings

• Breast Cancer
• Diabetes
• Chlamydia
• Colorectal Cancer

Increase in Services

• Blood pressure control for patients with hypertension
• Breast cancer screenings
• Recording of body mass index and blood testing for patients with diabetes

Using EHR Decision Support to Improve Asthma Care and Compliance

The Study

• Cluster randomization of clinics
• Intervention: Clinical decision support (CDSClinical decision support) embedded in EHR

Outcomes

• 6% greater use of controller medications (preventive or maintenance medications to help prevent asthma symptoms from occurring)
• 3% greater use of spirometry (a common office test used to diagnose asthma and other conditions that affect breathing)
• 14% greater use of asthma care plan
• Spirometry improved by 6% in suburban practices

EHRs Transforming the Clinical Process

A community hospital in Vermont recently implemented andEHRand reported:

• 60% decrease in near-miss medication events
• 20% increase in completion of daily fall assessment helping to avoid prolonged hospital stays
• 25% drop in the number of patient charts needing to be pulled for signing orders and dictated reports

Using EHRs to Improve Documentation and Coding

• Based on level of medical decision-making, ~50% of visits under-coded
• Rural family practice implementing EHR + Practice Management (EPM) system
• Increased case mix (type or mix of patients treated by a hospital or unit) by 10% over 2 years from 1.34 to 1.47
• EHR documentation templates in multi-specialty clinic
• Increased use of ICD code 99214 by 11%
• Average billable gain of $26/patient
• Increased revenue by >100K during the study period

Many health care providers have found that electronic health records (EHRs) help improve medical practice management by increasing practice efficiencies and cost savings. EHRs benefits medical practices in a variety of ways, including:

• Reduced transcription costs
• Reduced chart pull, storage, and re-filing costs
• Improved documentation and automated coding capabilities
• Reduced medical errors through better access to patient data and error prevention alerts
• Improved patient health/quality of care through better disease management and patient education

Electronic Health Records Create More Efficient Practices

EHR-enabled medical practices report:

• Improved medical practice management through integrated scheduling systems that link appointments directly to progress notes, automate coding, and managed claims
• Time savings with easier centralized chart management, condition-specific queries, and other shortcuts
• Enhanced communication with other clinicians, labs, and health plans through:
  • Easy access to patient information from anywhere
  • Tracking electronic messages to staff, other clinicians, hospitals, labs, etc.
  • Automated formulary checks by health plans
  • Order and receipt of lab tests and diagnostic images
  • Links to public health systems such as registries and communicable disease databases

Affect On Revenue: Automating Clinical Documentation and Orders

• Enhanced ability to meet important regulation requirements such as Physician Quality Reporting Initiative (PQRI) through alerts that notify physicians to complete key regulatory data elements
• Reduction of time and resources needed for manual charge entry resulting in more accurate billing and reduction in lost charges
• Reduction in charge lag days and vendor/insurance denials associated with late filing
• Charge review edits alerting physicians if a test can be performed only at a certain frequency
• Alerts that prompt providers to obtain Advance Beneficiary Notice, minimizing claim denials and lost charges related to Medicare procedures performed without Advance Beneficiary Notice

Electronic Health Records Reduce Paperwork

EHRs can reduce the amount of time providers spend doing paperwork.

Administrative tasks, such as filling out forms and processing billing requests, represent a significant percentage of health care costs. EHRs can increase practice efficiencies by streamlining these tasks, significantly decreasing costs.

In addition, EHRs can deliver more information in additional directions. EHRs can be programmed for easy or even automatic delivery of information that needs to be shared with public health agencies or for the purpose of quality measurement.

Electronic Prescribing (E-Prescribing)

Paper prescriptions can get lost or misread. With electronic prescribing (e-prescribing), doctors communicate directly with the pharmacy. An e-prescribing system can save lives (by reducing medication errors and checking for drug interactions), lower costs, and improve care. It is more convenient, cheaper for doctors and pharmacies, and safer for patients. In short, e-prescribing is an important, high-visibility component of progress in health information exchange.

Electronic Health Records Reduce Duplication of Testing

Because EHRs contain all of a patient's health information in one place, it is less likely that providers will have to spend time ordering—and reviewing the results of—unnecessary or duplicate tests and medical procedures. Less utilization means fewer costs.