An Introduction to Electronic Health Records

At PicnicHealth, we know that many people are unaware of how precisely electronic health records, also known as EHRs, work. It’s understandable—a lot of people still remember their doctors taking notes on medical charts and sheets of paper. Some still do. 

But EHRs have transformed the way medical records are used, stored, and communicated across medical practitioners.

What are Electronic Health Records?

The Office of the National Coordinator for Health Information Technology or ONC officially defines an electronic health record as a digital version of the paper charts that patients have grown accustomed to when they see a doctor. However, EHRs are more efficient and effective than paper in maintaining patient records.

EHRs provide a real-time, patient-centric record that becomes more immediately available and accessible to both the patient and medical personnel. It can be updated a lot more easily than a physical document, eliminates redundant paperwork, and prevents accidentally making use of an out-of-date chart or information.

What’s in an Electronic Health Record?

Typically, an EHR will contain the medical and treatment histories of a patient, providing a better and broader view of a patient’s history. The records can include the patient’s:

  • Complete medical history
  • Diagnoses and illness
  • Medications and prescriptions
  • Treatment plans
  • Immunization dates
  • Full allergy details
  • Radiology images and history
  • Laboratory tests and results

Who has access to these records?

EHRs can also only be created and managed by authorized providers. Because the file is in digital form, it’s easier to share the record with multiple authorized healthcare providers and organizations. This ability is inherently what EHRs are designed for: to share patient information and details with other providers such as pharmacies, emergency facilities, school and workplace clinics, medical imaging facilities, laboratories, and more. This gives clinicians who are directly involved in the patient’s care a good overview of a patient’s health information, allowing them to make better decisions.

Understanding Basic Terms

These are some of the basic terms to know about EHRs and EHR software.

Certification

Certification refers to the approval that is granted to EHR software that fulfills various requirements. In the U.S., the authority that decides what basic features that software handling EHR must possess is the Certification Committee for Health Information Technology (CCHIT).

Electronic Medical Record

You might be wondering the difference between an EHR and an EMR or electronic medical record. For the most part, EMR is simply an older term that is still widely used. This term is now more often used about clinical functions of EHR software, such as checking for interactions with drugs, allergies, and encounter documentation, among others. EHR is often used to refer to a system that holds records from more than one hospital or doctor’s office.

Integrated EHR

This refers to a form of EHR that can get integrated with practice management software. Some EHRs can function independently and are compatible with most practice management systems.

EHRs and its Challenges

Of course, no EHR is not perfect. Patients are understandably concerned about their records, which contain a great deal of highly sensitive and private information. Healthcare providers have many things to consider when it comes to choosing the right one as well. There are many stringent restrictions and requirements for software that will handle EHRs, and most of them are for the patients’ protection. Unfortunately, patients generally have no say in which EHR their providers use. Some independent EHRs will aggregate portions of a patients’ medical record. Some work through APIs (application programming interfaces) to collect standardized information from different providers. PicnicHealth collects the most complete records by going directly to your providers to collect all records, whether paper or digital, and put them into a single digital timeline.

Want someone to collect all of your medical records? Visit PicnicHealth.com to get access to all of your EHRs and more.